access to health care among under five children in...
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ACCESS TO HEALTH CARE AMONG UNDER FIVE CHILDREN IN THE
BANJARA COMMUNITY, KARNATAKA
BEVIN VINAY KUMAR V N
Dissertation submitted in partial fulfillment of the
Requirement for the award of
Master of Public Health
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
SREE CHITRA TIRUNAL INSTITUTE FOR MEDICAL SCIENCES AND
TECHNOLOGY
Thiruvananthapuram, Kerala. India – 695011
OCTOBER 2015
i
Acknowledgements
I thank the Lord almighty for helping me to come this far and for comfort during difficult times.
I would like to express my gratitude to my guide Professor Mala Ramanathan for guiding me
throughout the study and for teaching me about research and how to be a good researcher.
I would like to thank Professor TK Sundari Ravindran for help in conceptualizing the study topic
on marginalized groups.
I thank Dr K.R Thankappan, Dr V. Raman Kutty, Dr P. Sankara Sarma, Dr Biju Soman, Dr K.
Srinivasan, Dr Manju Nair, Dr Ravi Prasad Varma and Ms Jissa V. T for their valuable inputs. I
would like to thank Dr.Jayasingh, Deputy Registrar and Ms. Jayasree Neelakantan, UDC,
AMCHSS for all the administrative support rendered to facilitate the conduct of the study.
I thank Dr Solomon and the extended family in Basel Mission hospital, Gadag for taking care of
me during data collection. I would like to acknowledge with gratitude the contribution of
various authors who shared versions of their papers with me when the same were not accessible
through pubmed.
I would like to thank Aakshi K, Peeyush and Souvik P for the peer review during different stages
of the dissertation, mock presentations, late night discussions over a cup of coffee and for
standing by me and motivating me during difficult times. I would also like to thank Tijo G and
Minu A for all their support.
I would like to thank all the participants of the study for sharing their experiences which
enhanced my understanding of their problems.
Finally I would like to thank my wife, mom and dad for their support in my work.
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DECLARATION
I hereby declare that this dissertation titled “Access to health care among under five children
in the Banjara community, Karnataka” is the bonafide record of my original research. It has
not been submitted to any other university or institution for the award of any degree or
diploma. Information derived from the published or unpublished work of others has been
duly acknowledged in the text.
Bevin Vinay Kumar V N
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Trivandrum, Kerala
October 2015
iii
CERTIFICATE
Certified that the dissertation titled “Access to health care among under five children in the
Banjara community, Karnataka” is a record of the research work undertaken by Mr Bevin
Vinay Kumar V N in partial fulfilment of the requirements for the award of the degree of
“Master of Public Health” under my guidance and supervision.
Dr. Mala Ramanathan
Professor
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Trivandrum, Kerala
October 2015
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TABLE OF CONTENTS
LIST OF FIGURES
LIST OF TABLES
GLOSSARY OF ABBREVIATIONS
ABSTRACT
Chapter No Page No
Chapter 1 Introduction 1 - 5
1.1 Background 1
1.2 Rationale of the study 4
1.3 Research Question 4
1.4 Objectives 5
1.5 Chapterization plan for the dissertation 5
Chapter 2 Review of Literature 6 - 19
2.1 Type of care sough and facilities visited 7
2.2 Factors that affect health care utilization 8
2.2.1 Characteristics of the Primary care giver of the child 8
2.2.2 Economic status of the household 9
2.2.3 Caste differentials 10
2.2.4 Rural-Urban Residence 10
2.2.5 Sex of the child 11
2.2.6 Distance to the health facility 12
2.2.7 Provider related factors 12
2.3 Discrimination as a barrier to access care 13
2.3.1 Types of Discrimination 13
2.3.2 Consequences of Discrimination 15
2.4 Summary of Literature Review 16
2.4.1 Factors that affect utilization 16
2.4.2 Discrimination as a barrier to access health care 18
Chapter 3 Methodology 20 - 27
3.1 Study Design 20
3.2 Study Setting 20
3.3 Sample Size 21
3.4 Sample Selection 21
3.5 Subject Selection 22
3.6 Data Collection 23
3.7 Data Collection Tool 23
3.7.1 Quantitative component 23
3.7.2 Qualitative component 24
3.8 Ethical Considerations 24
3.9 Data Storage 25
3.10 Data Entry 25
3.11 Data Analysis 25
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Chapter No Page No
3.12 Variables 26
3.12.1 Dependent Variables 26
3.12.2 Independent Variables 26
3.12.3 Codes for Qualitative Analysis 27
3.13 Expected Outcome 27
Chapter 4 Results 28 - 48
4.1 Introduction 28
4.2 Sample Characteristics 28
4.2.1 Individual Characteristics 28
4.2.2 Household Characteristics 30
4.3 Self-reported experience of discrimination 31
4.4 Prevalence of Diarrhea, ARI and overall morbidity 33
4.5 Diarrhea health care seeking 33
4.5.1 Bivariate analysis with Prevalence of diarrhea as the
outcome variable
35
4.5.2 Correlates of facility visited for diarrhea 36
4.6 ARI healthcare seeking 37
4.6.1 Bivariate analysis with ARI as the outcome variable 38
4.6.2 Correlates of facility visited for ARI 39
4.7 Care seeking for Morbidity 40
4.7.1 Correlates of overall morbidity 40
4.7.2 Correlates of facility visited for Morbidity 41
4.8 Analysis of in-depth interviews 42
4.8.1 Four types of perceived discrimination 42
4.8.2 Reasons for being discriminated 46
Chapter 5 Discussion and Conclusions 49 - 56
5.1 Summary of key findings 49
5.2 Diarrhea and its correlates 50
5.3 ARI and its correlates 52
5.4 Self-reported experience of discrimination 54
5.5 Limitations of the study 55
5.6 Strengths of the study 55
5.7 Conclusions 56
5.8 Policy Implications 57
References
ANNEXURE I
ANNEXURE II
ANNEXURE III
ANNEXURE IV
ANNEXURE V
ANNEXURE VI
ANNEXURE VII
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List of Tables
Table No Title Page No
4.1 Individual profile of the primary care givers and
children, Gadag district, Karnataka
29
4.2 Household characteristics of the primary care givers,
Gadag district, Karnataka
30
4.3 Discrimination experienced at a health facility by
primary care givers in village and thanda (N = 20),
Gadag district, Karnataka
32
4.4 Prevalence of Diarrhea, ARI and overall Morbidity
(N=320), Gadag district, Karnataka
33
4.5 Distribution of children in village and thanda by
health care seeking for Diarrhea (N = 30), Gadag
district, Karnataka
34
4.6 Association between the prevalence of diarrhea with
water location, type of house and education of the
primary care giver in village and thanda, Gadag
District, Karnataka
35
4.7 Association between the facility visited for diarrhea
with the location of residence and education of
primary care giver, Gadag district, Karnataka
36
4.8 Distribution of children in village and thanda by
health care seeking for ARI (N = 60), Gadag district,
Karnataka
37
4.9 Association of the prevalence of ARI with water
location, type of house and education of the primary
care giver in village and thanda, Gadag district,
Karnataka
38
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Table No Title Page No
4.10 Association between the facility visited for ARI with
the location of residence and education of primary
care giver, Gadag district, Karnataka
40
4.11 Association of the prevalence of overall Morbidity
with water location, type of house and education of
the primary care giver in village and thanda, Gadag
district, Karnataka
40
4.12 Association between the facility visited for overall
Morbidity with the location of residence and
education of primary care giver, Gadag district,
Karnataka
42
List of Illustrations
Figure No Title Page No
1 Flowchart of literature review process
6
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Glossary
UNICEF United Nation’s Children Fund
NFHS-3 National Family Health Survey - 3
DLHS-4 District Level Household and Facility Survey - 4
SC Scheduled Caste
ST Scheduled Tribe
OBC Other Backward Caste
VJNT Vimuktha Jati and Nomadic Tribe
ARI Acute Respiratory Infection
PI Primary Investigator
SD Standard Deviation
BAMS Bachelor of Ayurveda, Medicine and Surgery
RMP Rural Medical Practitioner
ORS Oral Rehydration Salts
IMNCI Integrated Management of Neonatal and Childhood Illness
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ABSTRACT
Background
Variation in health care seeking is shaped by barriers to access. These barriers are determined by
individual traits or health system responses. Children constitute a vulnerable group whose care
is given primacy and therefore care seeking is most likely. By studying health care seeking
behaviors for childhood morbidities, access barriers that emanate from health systems can be
best understood. The study aims to describe patterns of health care utilization for diarrhea and
ARI among under 5 in Banjara and non Banjara groups in rural Karnataka.
Methods
Mixed methods approach was used - a cross-sectional comparison study for the quantitative
component with a structured interview schedule and negative case description for the qualitative
component using an interview guide. Primary care givers of Banjara (n=160) and non-Banjara
(n=160) children were surveyed from 16 randomly selected Banjara settlement and villages in
Gadag district. Analysis used R open source software and SPSS V21 for quantitative and
manual analysis for qualitative data.
Results
The prevalence of Diarrhea and ARI was 8.8 percent (95% CI 3 – 10.8) and 22.5 percent (95%
CI 14.3 – 16.9) and 13.1 percent (95% CI 5.8 – 15.4) and 26.9 percent (95% CI 17.75 –31.05)
among the non-Banjaras (village) and Banjaras (thanda) respectively. Government facility and
local providers were more used by Banjaras (11% and 28.9% vs 1.1% and 20%) whereas Non-
Banjaras used private providers (21.1% vs 17.8%). The education of the primary care giver and
their location was associated with the type of care sought. Self-reported experience of
discrimination did not vary between the two groups. However there is evidence suggestive of
class-based discrimination.
Conclusions
Banjaras had higher levels of morbidity and higher utilization of public sector facilities when
compared to non-Banjara groups. These choices may be shaped by class-based discrimination.
More specific tools are needed to capture this.
1
CHAPTER 1
INTRODUCTION
1.1 Background
Diarrhea and respiratory infections are major causes of morbidity and mortality among
children under five years of age. Deaths due to diarrhea and pneumonia account for about 30
percent of the deaths in children worldwide and 90 percent of these deaths occur in sub-
Saharan Africa and South Asia with India accounting for about 28 percent (UNICEF, 2012;
Walker et al, 2013). India has the highest burden of diarrhea in South Asia. It is an important
public health problem as most of these deaths are preventable (UNICEF, 2010).
The distribution of health outcomes are unequally distributed over segments of the
population and this distribution is influenced by the prevailing social, economic and political
conditions (Balarajan et al, 2011). Improvements in health outcomes in a population need
not be uniformly distributed across the population sub groups and is often influenced by
gender, caste, social class, urban-rural residence and geographical location (Bajpai and
Saraya, 2012)
Large inequities in health outcomes exist between Scheduled Tribes(ST), Scheduled
Caste(SC) and mainstream groups. There are differences in mortality and morbidity patterns
across these groups. As per the estimates of the National Family Health Survey (NFHS-3)
the infant mortality rate among SC and ST were 66.4 percent and 62.1 percent compared to
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48.9 percent among other groups who belonged to the general category. The under five
mortality among SC and ST groups was 88.1percent and 95.7 percent respectively, when
compared to 59.2 percent among those in the general category. The prevalence of diarrhea
among the three groups showed a similar trend (8.7 percent, 8.8 percent and 8.6 percent
among SC, ST and general category, respectively). However, the variation was observed in
those who were taken to a health provider for treatment, 60.7 percent and 54.3 percent among
the SC’s and ST’s and 64.9 percent in the general category. The prevalence of acute
respiratory infection among SC, ST and others was 5.3 percent, 4.6 percent and 7 percent and
the proportion who sought care from a health provider was 73.5 percent and 57.4 percent
among the SC and ST and 70.6 percent among the general category population groups (IIPS,
2007). These variations in health care seeking could be because of the barriers faced by
these communities in accessing care. Access refers to the use of health care, qualified by
need for care. Utilization is realized access and often used as a proxy for access (Levesque et
al, 2013).
The indigenous groups are people who identify themselves with pre colonial /pre settler
societies, who maintain a distinct language, culture and beliefs and have distinct social,
economic or political systems (UN, 2006). Globally indigenous people suffer from poor
health and likely to die younger than their non-indigenous counterparts (UN, 2014). Access
to and utilization of health services are low among the indigenous population and this is
attributed to their location, communication and socio-economic status (Marrone, 2007). In
India there are about 461 indigenous groups and they are usually referred to as adivasis or
Scheduled Tribes (STs). They are called scheduled tribe because tribes and tribal
communities were notified in accordance with article 342 of the constitution. However there
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are many ethnic groups that do not fall under this category and have varying status in
different states. The Banjaras or Lamanis are one such indigenous group who were nomadic
tribes. Their population is largely concentrated in the states of Karnataka, Maharashtra and
the erstwhile state of Andhra Pradesh. They were declared as a criminal tribe under the
British and after independence they were declared as a denotified ex criminal tribe. In
Maharashtra they are considered as VimukthaJati and Nomadic Tribe (VJNT), in undivided
Andhra Pradesh as Scheduled Tribe (ST) and in Karnataka as Scheduled Caste (SC). They
stay in a nuclear settlement with the houses clustered together called as thandas. The thandas
are considered part of the village although the two habitations could be distinct from each
other(Burman, 2010). Until the late 90’s the Banjaras were viewed with suspicion and
hostility due to their past history. The consequence of such labeling was mutual mistrust and
discriminatory behavior by the majority(World Bank, 2001).
Social groups classified as Scheduled Caste (SC), Scheduled Tribe (ST), Other Backward
caste (OBC) and General, each of which represents a very heterogeneous grouping. In a
community individuals or groups belonging to any of these groups may face exclusion or
more discrimination. However this may uniform across all contexts. A person belonging to
ST may not experience caste based discrimination in an urban city where they have some
degree of anonymity when compared to a village where identities are known and therefore a
person belonging to a disadvantaged caste may experience discrimination related to caste.
Similarly it is possible for individuals belonging to the SC category to not experience any
discrimination while accessing health care but face discrimination from the community
members in everyday life and vice versa in a livelihood context.
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What this indicates is that individuals in a society may face multiple axes of discrimination
like gender, class and religion and these vary by context. The context in which discrimination
is experienced is shaped by the kind of political, social or economic power that the individual
or the socio-economic group to which they belong possess. They may face deprivation or be
a victim of discriminatory targeting by the health system.
1.2 Rationale of the study
There are differences in health outcomes for children, particularly by caste affiliation, place
of residence and socio-economic status. The Banjaras are a group belonging to the Scheduled
Caste in Karnataka who are marginalized due to many factors and experience many barriers
in accessing health care. The aim of the study is to study the variation in barriers to access
health care for childhood illness among the Banjaras and compare it with the population of
non-Banjaras in the village that the thanda is a part of. Children are a vulnerable group, fall
sick very often and need more care and studying the barriers faced in seeking care for their
illness will give an idea of the overall barriers in the community for seeking care.
1.3 Research Question
What is the effect of community base discrimination on health care seeking, for childhood
ailments, that are more likely to be addressed?
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1.4 Objectives
1. To describe the pattern of health care utilization for acute respiratory infection and
diarrhea among children aged less than 5 years among Banjaras and non-Banjaras
2. To identify the various forms of self-reported discrimination experienced by the
Banjaras and non-Banjaras in health care setting
1.5 Chapterization plan for the dissertation
The chapter one gives a brief overview of introduction, rationale for the study, research
question and objectives. Chapter two provides a summary of the relevant literature that was
reviewed. Chapter three describes the methodology of the study including the interview tools,
data management, data analysis, variables and ethical considerations. Chapter four gives the
results along with the descriptive tables. Chapter five includes the discussion of the results,
the conclusions, strength and limitations of the study and policy implications.
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CHAPTER 2
REVIEW OF LITERATURE
The literature search was done on PubMed and Google Scholar for articles published
between 2005 – 2015 using the following search terms “Diarrhea”, “Diarrhoea”,
“utilization”, “ARI”, “Acute respiratory infection”, “access”, “under five morbidity”, “India”
and “discrimination”. Additionally the bibliography section of each article was scanned to
identify articles that might have been missed during database search.
Figure 1. Flowchart of literature review process
* Five articles that were not accessible were obtained by writing to the authors
Search from Pubmed and Google
Scholar yielded 192 results
Records were screened for eligibility
and full text access*
results
30 Key studies were identified (pertained to health care utilization for
childhood morbidity)
39 studies were included in the final
review
9 studies identified through
snowballing and expert
recommendation
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The articles were read to identify common themes across them. These themes were then
listed, categorized and summarized in terms of their relevance to the subject of research.
The themes identified were type of care sought and facilities visited, factors that affect health
care utilization, discrimination as a barrier to access care and types of discrimination.
There are several factors that affect health seeking in children, including the age of the child,
age of the mother, educational and economic status of the family, ethnic background, the
environment a child lives in, health beliefs of the family and factors related to the health
system.
2.1 Type of care sough and facilities visited
Health care seeking for childhood illness varied from 83 percent in Kerala to 28 percent in
rural UP (Pillai et al, 2003; Willis et al, 2009). The health care providers included allopathic
doctors in public and private facilities, Ayurvedic doctors, faith healers, chemists and peons
at a health facility. The utilization of public health facilities was comparatively low compared
to private facilities and it ranged from 5 percent in Bihar to 31 percent in Delhi. Private
providers were preferred for childhood illness and high utilization was seen in Bihar (73
percent) (Gupta et al, 2007; Thind, 2004). In Rajasthan and Orissa the utilization of public
health facilities was more when compared to private health facilities. The highest utilization
of public facilities was seen in Orissa (67percent) and lowest in UP (2 percent)(Lahariya et
al, 2012; Mohan et al, 2008). People in Bihar (22 percent) and rural areas of UP (50 percent)
preferred traditional providers for healthcare(Thind, 2004; Willis et al, 2009).In Rajasthan 64
8
percent did not seek any treatment compared to 17 percent in Kerala(Mohan et al, 2008;
Pillai et al, 2003).
2.2 Factors that affect health care utilization
2.2.1 Characteristics of the Primary care giver of the child
The educational status of the mother was significantly associated with health care utilization.
Higher education of the mother enhances the information available in deciding where to seek
care. The utilization of health care increased as the level of the education of the mother also
increased(Chakrabarti, 2012; Malhotra and Upadhyay, 2013; Sreeramareddy et al, 2006;
Thind, 2004). Mother’s educational status was also related to seeking care from a licensed or
unlicensed provider compared to no care being provided(Manna et al, 2013). Literate
mothers were more likely to seek care compared to illiterate mothers in Rajasthan(Mohan et
al, 2008). Two studies reported that the education of the mother was not associated with
health care utilization(Sreeramareddy et al, 2012; Sur et al, 2004). However a study done in
Kerala found that there was decreased utilization when the educational status of the mother
was higher. The reason for that being the better educated mothers would have better income
and they would have the resources in the household to seek care later on if the illness got
worse (Pillai et al, 2003).
A mother’s awareness and ability to recognize danger signs were also related to increased
utilization of care outside the home. Mothers who had knowledge of Oral Rehydration Salts
had a higher likelihood of receiving care from a health provider(Chakrabarti, 2012).But a
significant proportion of mothers in Delhi and Rajasthan were not aware of the danger signs
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and did not consider it necessary to seek care(Gupta et al, 2007; Mohan et al, 2008). Tribal
people of Chandrapur district in Maharashtra preferred private providers and faith healers for
care for neonatal danger signs as they felt that they were the specialists for treating such
conditions (Deshmukh et al, 2010).
Perception of severity of the illness affected the way in which care was sought. Mothers did
not seek care for their child when they perceived that the illness was mild and would resolve
on its own(Das et al, 2013; Pillai et al, 2003). Children with more than one illness (such as
diarrhea and ARI) were more likely to seek care than those afflicted with just one ailment
(Thind, 2004). Severity of the illness was associated with increased care seeking at a health
facility (Chakrabarti, 2012; Sreeramareddy et al, 2006, 2012). In a study done in Uttar
Pradesh one of the reason mentioned for not receiving care was because the mother did not
perceive it to be severe (Willis et al, 2009).
2.2.2 Economic status of the household
Economic status of the household acts as an enabler or a barrier to seek care. Increased
utilization was seen when the economic status of the household was better(Raushan and
Mutharayappa, 2014; Thind, 2004). Poor economic status of the household acted as a barrier
in seeking care and even if care was sought it was delayed. Children belonging to a rich
family were more likely to seek care compared to the poor(Malhotra and Upadhyay, 2013).
Economic status of the household was also related to where the care was sought. Women
belonging to rich households were more likely to visit a private health care provider
compared to the poor household for the sickness of their child(Sreeramareddy et al, 2012).
10
Children belonging to economically disadvantaged families are more likely to use alternative
system of medicine (Sreeramareddy et al, 2006; Willis et al, 2009). However Pillai(2003)
reported that utilization decreased when the household was better off economically due to the
availability of resources to seek care if the illness got worse.
2.2.3 Caste differentials
Children belonging to Scheduled Caste/Tribe or Other Backward Caste are more likely to fall
sick compared to the general population and are less likely to utilize health services. The
children belonging to the Scheduled Caste/Tribe were more likely to be non-users of health
care for illness(Nayar, 2007; Thind, 2004). Children belonging to higher caste were better off
in accessing care compared to the SC/ST or OBC’s. Road connectivity mattered to people
belonging to SC and ST and ST’s were the main users of government services(Raushan and
Mutharayappa, 2014).Families belonging to lower caste in rural Rajasthan were less likely to
seek care from qualified physicians when compared to those of the upper caste(Mohan et al,
2008). Chakrabarti (2012) observed that the probability of seeking care was high among the
Scheduled Caste indicating that they are more prone to contracting diarrhea or acute
respiratory infection or more likely to seek care when compared to others.
2.2.4 Rural-Urban Residence
There is unequal distribution of health care professionals and health infrastructure in urban
and rural areas with more of them being concentrated in urban areas and this leaves people
11
residing in rural areas with limited options to seek care. Differences were seen in the ability
to seek care and also the choice of the provider. Most of the people in rural Rajasthan did not
seek care(Mohan et al, 2008). People living in rural areas preferred to seek care from
alternate systems as the healthcare facilities were distant (Pillai et al, 2003). Those residing
in rural areas had a higher odd of seeking treatment when compared to those in urban areas
(Malhotra and Upadhyay, 2013). Care seeking for fever/cough in rural areas was more likely
to be from a public health provider. The utilization of private health care providers was low
in rural areas due to them being expensive or lack of private providers in the
area(Sreeramareddy et al, 2012).
2.2.5 Sex of the child
Sex of the child is an important predictor of health care utilization. The probability of seeking
care was low if the child was a female(Chakrabarti, 2012; Thind, 2004). Male child had a
lower odd of experiencing delay in seeking care compared to the female child(Malhotra and
Upadhyay, 2013). In rural Uttar Pradesh it was seen that private unqualified providers were
preferred for seeking care for the male child compared to the female, however public health
care utilization was more for female child than male child. Reason for that could be that
unqualified providers were seen as being more superior to the public health care providers.
Mothers were less likely to report illness in female child and the time taken to recognize the
symptoms was more than two days when compared to the male child(Willis et al, 2009).
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2.2.6 Distance to the health facility
Distance to the health facility is one of the major barriers to access health care. Utilization
depends on where the facility is located and the means to reach the facility. In Kerala it was
seen that most of the people in rural areas sought care from alternate systems for sickness of
their child which could indicate the lesser availability of allopathic care(Pillai et al, 2003).
Distance to the health facility posed a major problem and resulted in delays in presenting to
the health facility(Malhotra and Upadhyay, 2013) and was also a reason for mothers not
seeking care from a public health provider for diarrhea (Sreeramareddy et al, 2012). Even
when the perception of distance as a barrier is overcome, transportation and connectivity to
the health facility acts as another barrier to seek care. Raushan and Mutharayappa (2014)
reported that people from the Scheduled Tribe were less likely to seek care from a health
facility if the village did not have any road connectivity. Availability of health services close
to the village was associated with increased access. In rural Uttar Pradesh about 4 percent to
7 percent of the households reported lack of transportation as a reason for not seeking care
(Willis et al, 2009). Although distance is seen a barrier to access care, a study done in eight
states in India indicate that the quality of the provider was given more importance over the
distance of the facility in deciding where to seek care(Lahariya et al, 2012).
2.2.7 Provider related factors
In a study done among sick tribal neonates in Maharashtra the parents preferred private
provider over the public provider for seeking treatment for diarrhea. Private providers were
perceived by the parents as being specialists for such treatment and they were always
13
available in times of emergency. The treatments that they provided in the form of saline or
injection were considered to give rapid relief. However the government providers were not
available in times of emergency and even if they were available they did not pay the desired
attention to the child. The medicines available in the government centers were considered to
be cheap and not offering any relief(Deshmukh et al, 2010).A study in developing countries
like Vietnam, Malaysia, Cambodia and Lao PDR found that lack of services, lack of
medicines, long waiting times, cost of service, lack of privacy and poor communication
contributed to low satisfaction among users of health care services (Martinez et al, 2012).
2.3 Discrimination as a barrier to access care
Discrimination is defined as the unjust or prejudicial treatment of different categories of
people especially on the grounds of race, age or sex. Discrimination can not only affect
individual health but also reduces compliance with treatment and acts as a barrier in seeking
health care. It affects the trust in health care providers(Akhavan and Tillgren, 2015). Studies
have reported an association between self-reported discrimination, mental and physical
health(Lewis et al, 2015).
2.3.1 Types of Discrimination
Discrimination due to health care system could be operationalized at least two levels i.e
structural and individual level. Structural discrimination refers to generally accepted norms
and behaviors in social structures and institutions that act as obstacles for subordinate groups.
14
This form of discrimination would prevent individuals and groups from enjoying equal rights
and opportunities possessed by dominant groups and it could be intentional or unintentional
(Chatterjee and Sheoran, 2007). It could also be in the form of laws or legislations that havea
negative effect on an individual or a group. An example of laws that could be discriminatory
are the many laws against leprosy patients in India which provides for exclusion, segregation
and treatment, grounds for divorce and barring from holding or contesting polls (Rukmini,
2015).It also may be in the form of limiting access by not allocating resources to certain
geographical locations or segments of the population for political-economic reasons such as
the limited access to health care to the people living in the Andaman and Nicobar islands
(Shamim, 2014). Structural discrimination could take the form of differences in treatment
regimes for different groups, inadequate spending on health care for marginalized compared
to the mainstream population and not addressing the cultural barriers for these marginalized
groups(Henry et al, 2004). Access to information is an area where certain social groups do
not receive information required by them in a form comprehended by them to make choices
regarding their health (Thorat and Sadana, 2009).
Discrimination at another level in the health system targets specific individuals. Individuals
experience discrimination because of their own identity or specific attributes of the group
that they belong to by the larger community or the health care system. A study in Gujarat and
Rajasthan found that most of the children belonging to the Scheduled Caste faced
discrimination in health care setting if the provider was of another caste group. The
discrimination was in the form of refusal to touch, making them sit separately, long waiting
time and spending less time during house visits by health workers (Acharya, 2010). Religion
based discrimination has been reported from Mumbai. The forms of discrimination
15
experienced by muslim women were rude language, abuse in the labor ward, health care
provider speaking in a language they donot understand, derogatory comments targeted
towards the community and stereotypical behavior by the health care providers (Kandayand
Tanwar, 2013).
The discrimination by the health care system could be in the form of denial of services to
marginalized groups or using them to achieve government targets, a form of “discriminatory
targeting”. This can be seen in the high incidence of Lamani women undergoing
hysterectomy in private hospitals in Karnataka and most of these were unnecessary. There
was discriminatory targeting by private providers for financial gains and targeted towards a
community that is very unlikely to question them (Sivanandan, 2015). Examining data from
the National Family Health Surveys - 3 (IIPS, 2007) surgical sterilization in women
accounted for 37.3 percent of the total contraceptive use compared to 1 percent in men,
which indicate selective targeting of women in family planning services, another form of
discriminatory targeting.
2.3.2 Consequences of discrimination
People belonging to marginalized groups experience some form of discrimination or
exclusion within communities in which they live. The health systems in which these
communities live in would also engage in the same kind of practices, thus reinforcing or
exacerbating the discrimination. Data from NFHS-3 reveal that the health status and under
nutrition indicators for Scheduled Castes (SC) and Scheduled Tribes (ST) are relatively
worse off than other groups. This is because; in addition to the low income and poor
16
education they have restricted access to public health services by government institutions.
Even for individuals with similar standard of living and educational levels the health status of
SC and ST populations are lower than the general population. This is indicative of the
unequal access to public services related to their caste and experiences of untouchability and
discrimination (Thorat and Sadana, 2009).
2.4Summary of Literature Review
The utilization of health care facilities varied across different states in India. Primary care givers of
children preferred to seek care from private providers with overall utilization of government facilities
being poor. Only in a few states was the utilization of government health facilities more than that of
private facilities.
The providers generally visited were doctors with modern medicine training, ayurvedic doctors, faith
healers, traditional healers, chemists and peons at health facilities.
2.4.1 Factors that affect utilization
Characteristic of the primary care giver
The education of the primary care giver could affect health care utilization in children. Education of
the primary care giver tended to enhance the information available to them and in turn this helped
them to decide where to seek care and from whom. Such knowledge lead to increased utilization.
However it could also lead to decreased utilization as the mother is aware of what needs to be done
for the child and could end up treating the child at home and seeking care when the illness gets worse.
Education may not play an important role in places with limited health care options as the primary
care giver would have to take the child to whatever is available. Utilization was high when the
primary care givers were able to recognize danger signs in their children. Education was found to
play a role in the ability to recognise danger signs, especially for ARI.
17
Economic status of the household
Economic status of the household can act as an enabler or a barrier in seeking care. Better off
households were more likely to seek care from private providers where they had to pay for services.
Poor households delayed seeking care due to their inability to pay for services and increased
utilization of government facilities was seen among them. Although from a health system perspective
it is desirable that there is increased utilization of government services so that people do not have to
incur out of pocket expenditure but the reason for going there is their inability to pay for private
providers.
Caste
Inequality in the distribution of ill-health is seen in children with more children belonging to SCT/ST
or OBC communities falling sick. The utilization of health care was low among these social groups
and this could be because of the barriers they face in seeking care. They could also have increased
utilization as they fall sick very often.
Rural-urban divide
Utilization of health care matters if the child resides in a rural or urban area. The distribution of
health care professionals and health facilities are skewed towards urban areas which increases the
utilization for those living there. Decreased utilization is seen in rural areas where there are not many
facilities and even if they do exist they may come with a cost. There was increased utilization of
traditional providers or alternative system of medicine in rural areas as they are more likely to be
found in these places.
18
Sex of child
Sex of the child was important in care seeking and the type of provider visited. A male child often
gets preference over the female child in seeking care from a health facility. This is influenced by the
prevailing norms in the society regarding the girl child. Increased utilization of government facilities
was seen for the female child and unqualified providers for the male child, the reason being
unqualified providers being viewed as superior form of providers.
Distance to the health facility
Distance to a health facility is one of the major barriers to access healthcare. The location of the
facility and the time taken to reach it does affect utilization. If the health facilities were far off then
there alternate system of medicine was preferred as these are closer. Distance could also lead to delay
in the child being taken to a health facility. The time taken to reach a facility depends on the
connectivity and available transportation with increased utilization with better connectivity.
Although distance is a barrier in seeking care the quality of the provider was given preference over
distance in deciding to seek care.
Provider related factors
The provider related factors that affect utilization of services were lack of services, medicines
shortage, long waiting times, privacy concerns and poor communication which affected care seeking.
Government health facilities were often seen as providing inferior services compared to the private.
The medicines in government hopsitals were thought to be inferior compared to the saline or injection
that was provided in the private hospital which provided fast relief.
2.4.2 Discrimination as a barrier to access health care
Discrimination due to a health system could be operationalized at two levels i.e structural and
individual. Structural discrimination in health care could be in the form of laws or legislation that has
19
a negative effect on individuals or groups. Individuals might face discrimination because of their
own identity or any specific attributes of the social or religious group they belong to. This may take
various forms like refusal to touch, making them sit separately, longer waiting times and spending
less time during house visits by community workers. Another form of discrimination that is practiced
by the health system is discriminatory targeting where marginalized groups are used to achieve
government targets.
20
CHAPTER 3
METHODOLOGY
3.1 Study Design
The study used a mixed methods approach i.e explanatory sequential design, using both
qualitative and quantitative approaches to collect data. This involved collecting and
analyzing the quantitative data followed by a qualitative approach to explain the results.
Cross-sectional design was chosen over retrospective cohort design as it would enable us to
study multiple outcomes i.e prevalence of diarrhea and ARI in childhood and the care
seeking for this illness. In a retrospective cohort the follow up stops with the development of
the outcome so technically the study would stop once the child is identified with diarrhea or
ARI. We would not be able to capture and analyze health care seeking for these conditions.
For this reason, a cross-sectional study design was preferred.
3.2 Study Setting
The study was conducted in Gadag district, Karnataka. The proportion of Banjaras among
the total population in Gadag district is 4.7% next only to Gulbarga which has 7.2%, the
highest Banjara population in Karnataka(Census, 2011). Gadag was selected as the overall
prevalence of morbidity among children under five years of age was 32.6% compared to
19.2% in Gulbarga(Lahariya et al, 2012). Acute Respiratory Infections (ARI) and Diarrhea
21
in children was chosen as markers of the health status of the children with the assumption
that it reflects the overall health status of the community.
3.3 Sample Size
The sample size was estimated using open epi version 3.03. Data from NFHS-3(IIPS, 2007)
was used to calculate the proportion of children with ARI/fever and diarrhea and the
proportion who sought care from a medical facility among SC/ST and others. Conditional
probability of children falling sick and seeking care from a medical facility was obtained by
multiplying the two probabilities which was estimated to be 0.2527 for the SC/ST’s and
0.2606 for others. Using a precision of 10% and design effect of 2 the sample size was
estimated to be 145 primary care givers of Banjara children and 148 primary care givers of
non Banjaras. The calculated sample size was rounded off to 160 for both the groups. The
final total sample size was 320 primary care givers.
3.4 Sample Selection
The sample was selected in two stages. The first stage was for selection of thandas/villages,
which were to be 16 in number so as to obtain 160 primary care givers in each sub-group.
For this, the population size of all the thandas were listed (N = 90319), then the cumulative
sum of the population size across thandas was calculated. A random number between from 1
to 5645 (that constitutes one-sixteenth of the total number of persons living in tandas in
Gadag), was generated which was 5150. Starting from the first person in the population, the
22
thanda where the 5150th
person resides was selected. By adding 5645 to 5150 the second
thanda to be included was identified. This process was repeated until 16 thandas were
selected. The villages to which the thanda belonged were also selected to obtain the non-
Banjara sample for the study.
In the second stage upon entering the central square of the village/thanda a coin was tossed to
decide the direction to start and this method was followed across all thandas and villages.
The first house encountered was selected and then every 2nd
household was systematically
selected until 10 primary caregivers of children under-five years are enrolled in the thanda or
village. In houses where there was more than one eligible subject a coin was tossed to decide
the subject to be enrolled.
For the case studies, cases who reported extreme experience of discrimination and care
seeking were selected from those who were interviewed in the quantitative study.
3.5 Subject Selection
Inclusion criteria for the quantitative component:
1. Primary care givers of children aged less than five years
2. Residents of Gadag district
Inclusion criteria for the qualitative component
1. Primary care givers who reported extreme experience of discrimination and faced
difficulties in care seeking for the child
23
3.6 Data Collection
Data collection was carried out by the Principal Investigator (PI) from 1st July, 2015 to 7
th
August, 2015. Three forty nine eligible households were visited i.e 171 households in the
thandas and 178 in the villages. Among the 349 eligible households, 11 (6.4%) in the
Banjara/thanda group and 18 (10.1%) in the non-Banjara/village group declined to participate
in the study. The non-responders were replaced with households from the respective thandas
and villages to achieve the sample size of 160 for each group. Informed consent was
obtained prior to data collection. Care was taken to ensure the privacy and confidentiality of
the respondents.
3.7 Data Collection Tool
3.7.1 Quantitative component
Data was collected using an interview schedule, including an Index of Discrimination tool.
The interview scheduled captured the basic demographic features of the primary care giver
and the child, preferred provider for ARI and diarrhea, experience of ARI or diarrhea in the
past two weeks for the child and health care seeking for these morbidities. The index of
Discrimination tool has been adapted from a study done among Dalit children in Gujarat and
Rajasthan(Acharya, 2010). The tool captures the types of discrimination experienced, the
area in the health care system where it was experienced and the kind of providers who
practiced it. The types of discrimination include being spoken to rudely or derogatorily,
24
inappropriate touch or not touching, longer waiting time than others and not giving adequate
information regarding the condition. The areas where discrimination was experienced
includes government or private facility, different places within the facility like registration
counter, interaction with the provider, laboratory or X-ray investigations, dressing room, in-
patient admission and visit by health workers in the community. The kind of providers
includes physicians, nurses, technicians, clerical staff and health workers in the community.
3.7.2 Qualitative component
Interview guidelines were used to document any extreme experiences by the community in
seeking care for childhood illness or experiences of discrimination by the respondents.
The interview schedule and interview guidelines were developed in English, then translated
into Kannada and then back translated into English by a member belonging to the local
community. Necessary changes were made to suit the dialect being spoken in Gadag district.
3.8 Ethical Considerations
The study was carried out only after review by the Ethics Committee of Sree Chitra Tirunal
Institute for Medical Sciences and Technology (SCTIMST). Written informed consent was
obtained from the participants. The interviews were conducted in an environment where the
respondent felt secure and comfortable. The information that was collected was kept secure
and not shared with anyone during or after the interview other than the PI and Guide. Care
25
was taken to protect the identity and location of the respondent; no identifiers were
mentioned in the interview schedule other than a unique code.
3.9 Data Storage
All data including the consent forms are secured by the PI, who shall bear sole responsibility
for keeping the data secure and for any breach of confidentiality. All completed interview
schedules, consent forms and notes would be destroyed upon completion of three years from
the date of acceptance of the thesis in keeping with regulatory requirements (ICMR, 2006).
3.10 Data Entry
Data entry and cleaning was done using Epidata Manager and Entry Client, version 2.0.7
(Lauritsen and Bruus, 2008) and exported to csv (comma-separated values) format.
English translated transcripts of interviews were entered in MS word for analysis.
3.11 Data Analysis
Data was analyzed using R, version 3.2.2 and SPSS, version 21. Descriptive analysis was
done to describe and compare the characteristics of both the non-Banjara/village and
Banjara/thanda population. Bivariate analysis was done to test the relationship between
dependent variable and independent variables. The qualitative data was analyzed manually
using deductive codes that were identified by reading the translated transcripts.
26
3.12 Variables and Codes
3.12.1 Dependent Variables
The dependent variables were:
1. Diarrhea or ARI in children- Any children in the household who had diarrhea or ARI
in the past two weeks preceding the survey
2. Care seeking for Diarrhea or ARI- The type of care provided or the facility visited by
the primary care givers of children with diarrhea or ARI
3. Discrimination experienced at a health facility- Any discrimination experienced by
the primary care giver during the visit to a health facility as reported by them
3.12.2 Independent Variables
Characteristics of the Primary Care Giver and the Child
1. Age: Age in completed years as reported by the respondent
2. Educational status: If the primary care givers had ever attended school and the
years of formal education completed. The educational status was further
categorized into lower primary (1-4), upper primary (5-7), secondary (8-10), PUC
and above (>10) and no education.
3. Autonomy: The permission required by the primary care giver to seek care
outside the house for the child’s illness
4. Relationship to the child: Relationship of the child to the primary care giver as
reported by them
27
5. Age of the child: Age in months as reported by the primary care giver
6. Sex of the child: Male or Female as reported by the primary care giver
Characteristics of the Household
1. Sanitation Facility: The type of toilet facility used by members of the household.
Categorized as toilet within the household, no facility or open spaces and
dysfunctional toilets
2. Type of house: Categorized as pucca, semi pucca and kachha
3. Farm animals: Household owning any farm animals
4. Water source location: The source of water used for drinking water was
categorized into on the premises and elsewhere, if elsewhere then the time taken
to fetch water was recorded
5. Religion: Religion of the head of the household
6. Caste: Caste/Tribe to which the head of the household belongs to
3.12.3 Codes for Qualitative Analysis
The codes for analysis were to be identified after reading through the interviews and listing
the types of perceived discrimination and the felt reasons for the same.
3.13 Expected Outcome
The study aims to find out the prevalence of diarrhea between Banjaras and non-Banjara
groups in the village, the health care seeking behavior between the two communities and the
discrimination faced by them in a health care facility. The case studies would help to
document the nature of discrimination and the extent to which it hinders access.
28
CHAPTER 4
RESULTS
4.1 Introduction
This chapter describes the results of the quantitative and qualitative components of the study.
The quantitative component was a cross-sectional comparison which includes description of
the sample characteristic and bivariate analysis. Multivariate analysis was not done as the
predictor variable had multiple distinct categories which could not be merged. The resultant
table had cells with less than 10 cases, an analysis with this input could lead to spurious
results and therefore the effort at multivariate modeling was avoided. The qualitative
analysis included manual coding and thematic analysis. The discussion considered the
quantitative and qualitative findings holistically.
4.2 Sample Characteristics
The baseline characteristics have been compared between the Banjara/thanda and the non-
Banjara/village and presented in tables.
4.2.1 Individual Characteristics
The study population consisted of 320 primary care givers of children, 160 in the Banjara/
thanda and 160 in the non-Banjara/village. Overall the mean (SD) age of the primary care
givers was 25.35 (5.71). The average age of the primary care givers in the Banjara/thanda
29
(M= 24.94, SD = 5.44) and non-Banjara/village (M = 25.76, SD = 5.95) was similar. Just
about half the primary care givers in the Banjara/thanda (52.5%) had attended school when
compared to those in the non-Banjara/village (81.9%). Among those who had attended
school the average years of schooling was more in the non-Banjara/village (M=8.18,
SD=3.08) when compared to those in the Banjara/thanda (M=5.79, SD= 3.2). The average
age (in months) of the children under five years in Banjara/thanda (M = 24.89, SD = 16.26)
and non-Banjara/village (M = 26.13, SD = 15.72) were similar.
Table 4.1.Individual profile of the primary care givers and children, Gadag
district,Karnataka
Characteristics Village
[N=160]
n (%)
Thanda
[N=160]
n (%)
Total
[N=320]
n(%)
Primary care giver
Mother
Father
Grandmother
Aunt
Uncle
149 (93.1)
8 (5)
2 (1.3)
1 (0.6)
0 (0)
142 (88.8)
12 (7.5)
4 (2.5)
1 (0.6)
1 (0.6)
291 (90.9)
20 (6.3)
6 (1.9)
2 (0.6)
1 (0.3)
Permission to take child to
a facility
No permission
Some permission
43 (26.9)
117 (73.1)
31 (19.4)
129 (80.6)
74 (23.1)
246 (76.9)
Attended School
Yes 131 (81.9) 84 (52.5) 215 (67.2)
Education of primary care
giver
Lower Primary (1-4)
Upper Primary (5-7)
Secondary (8-10)
PUC & above(>10)
No education
17 (10.6)
36 (22.5)
55 (34.4)
23 (14.4)
29 (18.1)
29 (18.1)
37 (23.1)
12 (7.5)
6 (3.8)
76 (47.5)
46 (14.4)
73 (22.8)
67 (20.9)
29 (9.1)
105 (32.8)
Sex (Child)
Female
Male
76 (47.5)
84 (52.5)
79 (49.4)
81 (50.6)
155 (48.4)
165 (51.6)
30
4.2.2 Household Characteristics
There is not much difference in the availability of a toilet facility, transport and BPL card
status between Banjara/thanda and non-Banjara/village. Households in the thanda (45%) had
more livestock than households in the village (36.9%). More people in the thanda (35.6%)
had no access to water source closer to home but the average time taken to fetch water was
more for the village people (M = 19.68, SD = 10.24) when compared to the time taken to
fetch water in the thanda (M = 15.54, SD = 8.62). The kind of care that was preferred for
episodes of diarrhea or ARI did not differ across Banjara/thanda and non-Bajara/village.
Less than half the people in the Banjara/thanda and the non-Banjara/village preferred to go to
a RMP i.e unqualified provider for diarrhea or ARI.
Table 4.2. Household characteristics of the primary care givers, Gadag district,
Karnataka
Characteristics Village
[N=160]
n (%)
Thanda
[N=160]
n (%)
Total
[N=320]
n (%)
Toilet facility
Pit latrine
No facility/open
spaces
Dysfunctional
42 (26.3)
116 (72.5)
2 (1.2)
48 (30)
109 (68.1)
3 (1.9)
90 (28.1)
225 (70.3)
5 (1.6)
Transport*
Motorcycle/Scooter
Car
Animal drawn cart
Cycle
Mini van
Tractor
Tempo
Auto
None of the above
46 (28.8)
4 (2.5)
16 (10)
17 (10.6)
4 (2.5)
5 (3.1)
1 (0.6)
2 (1.25)
90 (56.3)
46 (28.8)
3 (1.9)
11 (6.9)
13 (8.1)
1 (0.6)
3 (1.87)
0 (0)
1 (0.6)
94 (58.8)
92 (28.8)
7 (2.2)
27 (8.4)
30 (9.4)
5 (1.5)
8 (2.5)
1 (0.3)
3 (0.9)
184 (57.5)
Continued….
31
Characteristics Village
[N=160]
n (%)
Thanda
[N=160]
n (%)
Total
[N=320]
n (%)
Livestock*
Cows/Bull/Buffaloes
Goats
Sheep
Chicken/Ducks
No Animals
48 (30)
8 (5)
11 (6.9)
16 (10)
101 (63.1)
47 (29.4)
9 (5.6)
26 (16.3)
9 (5.6)
88 (55)
95 (29.7)
17 (5.3)
37 (11.6)
25 (7.8)
189 (59.1)
Water source
In own dwelling
In own yard/plot
Elsewhere
46 (28.8)
67 (41.9)
47 (29.3)
32 (20)
71 (44.4)
57 (35.6)
78 (24.4)
138 (43.1)
104 (32.5)
BPL card 124 (77.5) 131 (81.9) 255 (79.7)
Religion
Hindu
Muslim
143 (89.4)
17 (10.6)
160 (100)
0 (0)
303 (94.7)
17 (5.3)
Preferred Provider for
diarrhea
Government Facility
Private Hospi/Clinic
RMP*
Pvt- BAMS
33 (20.6)
66 (41.3)
24 (15)
37 (23.1)
29 (18.1)
59 (36.9)
28 (17.5)
44 (27.5)
62 (19.4)
125 (39.1)
52 (16.2)
81 (25.3)
Preferred Provider for
ARI
Government Facility
Private Hospi/Clinic
RMP^
Pvt- BAMS
30 (18.8)
62 (38.7)
28 (17.5)
40 (25)
29 (18.1)
57 (35.7)
29 (18.1)
45 (28.1)
59 (18.4)
119 (37.2)
57 (17.8)
85 (26.6) * Individual households had more than one vehicle or livestock in the household
^ RMP- Rural Medical Practitioner
4.3 Self-reported experience of discrimination
There was not much difference in the self-reported experience of discrimination at a health
facility between the Banjara/thanda (6.9%) and non-Bajara/village (5.6%). Overall 20
32
(6.3%) reported some kind of discrimination experienced at a health facility. Table
4.3.shows the distribution of the facility, provider who discriminated and the form of
discrimination. Most of them experienced discrimination at a government facility. Nurse
was the healthcare personnel who discriminated the most followed by the physician. The
main form of discrimination experienced by the non-Banjara/village people was rude or
derogatory behavior by the healthcare personnel. In the Banjara/thanda the main forms of
discrimination were rude or derogatory behavior followed by rough touch and not spending
enough time.
Table 4.3. Discrimination experienced at a health facility by primary care givers in
village and thanda(N = 20), Gadag district, Karnataka
Characteristics Village
[N=9]
n (%)
Thanda
[N=11]
n (%)
Total
[N=20]
n(%)
Facility where discrimination was
experienced
Government
Private
Both
5 (55.6)
3 (33.3)
1 (11.1)
9 (81.8)
2 (18.2)
0 (0)
14 (70)
5 (25)
1 (5)
Providers who discriminated
Doctor
Nurse*
Xray/Lab
Registration counter
ASHA
4 (44.4)
4 (44.4)
0 (0)
1 (11.1)
1 (11.1)
2 (18.2)
9 (81.8)
1 (9.1)
0 (0)
0 (0)
6 (30)
13 (65)
1 (5)
1(5)
1 (5)
Forms of discrimination ^
Rude/Derogatory behavior
Touch was rough
Not spending enough time
Avoided touching
Made to wait for long
Inadequate information
5 (55.5)
1 (11.1)
1 (11.1)
1 (11.1)
1 (11.1)
2 (22.2)
7 (63.6)
5 (45.5)
3 (27.3)
1 (9)
1 (9)
0 (0)
12 (60)
6 (30)
4 (20)
2 (10)
2 (10)
2 (10) *one individual in thanda and village experienced discrimination by two providers
^multiple experiences of different forms of discrimination
33
4.4 Prevalence of Diarrhea, ARI and overall morbidity
The prevalence of diarrhea (13.1% vs 8.8%), ARI (26.9% vs 22.5%) and overall morbidity
(37.5% vs 29.4%) was more in the Banjara/thanda compared to the non-Banjara/village. The
overall morbidity in the sample was 33.4 percent. Only 2.2 percent had both diarrhea and
ARI. Out of 107 children with diarrhea and ARI, 23 (21.5%) did not seek care outside the
home. Among these, 16 (69.5%) treated the child at home with medications that were left
over from a previous visit to a facility with similar symptoms, 4 (17.4%) of them did not
have money to take the child to the facility and the others provided some home remedy or
felt the illness was not severe to seek care outside.
Table 4.4. Prevalence of Diarrhea, ARI and overall Morbidity (N=320), Gadag district,
Karnataka
Characteristics Village
[N=160]
n (%)
Thanda
[N=160]
n (%)
Total
[N=320]
n(%)
Only Diarrhea
Yes 11 (6.9) 17 (10.6) 28 (8.8)
Only ARI
Yes 33 (20.6) 39 (24.4) 72 (22.5)
Both ARI and Diarrhea
Yes 3 (1.9) 4 (2.5) 7 (2.2)
Morbidity
Yes 47 (29.4) 60 (37.5) 107 (33.4)
4.5 Diarrhea- health care seeking
Among the 35 children with diarrhea 5 (14.3%) did not seek any care outside the home.
Only one child out of the 35 who had diarrhea had blood in the stool.
34
Among those who sought care, about 36.8% of primary care givers in the Banjara/thanda
provided some form of treatment at home before going to the facility. The number of days
following which the child was taken to a facility was similar across thanda (M= 1.26, SD =
1.36) and village (M =1.45, SD= 1.75). The preference for government facility was more
among those in the thanda (26.3%). About 80 percent of the children with diarrhea were
given antibiotics with 47.6 percent of children in the thanda with diarrhea receiving injection
for which there was no record or the primary care givers were not aware of the kind of
injection that was administered. Only one child was given Oral Rehydration Salts (ORS) for
the management of diarrhea.
Table 4.5. Distribution of children in village and thanda by health care seeking for
Diarrhea (N = 30), Gadag district, Karnataka
Variables Village
(N = 11)
n (%)
Thanda
(N = 19)
n (%)
Total
(N = 30)
n (%)
Any treatment at home
before going to facility
Yes 2 (18.1) 7 (36.8) 9 (30)
Choice of facility
Government
Private doc/clinic
BAMS
Others*
1 (9.1)
6 (54.5)
1 (9.1)
3 (27.3)
5 (26.3)
8 (42.1)
2 (10.5)
4 (21.1)
6 (20)
14 (46.7)
3 (10)
7 (23.3)
Medicines Prescribed^
Antibiotics
Antimotility
Zinc
Others
Unknown pill or syrup
Antibiotic-injection
Unknown injection
10 (73.7)
3 (27.3)
0 (0)
6 (54.5)
0 (0)
1 (9.1)
2 (14.3)
14 (90.9)
2 (10.5)
1 (5.3)
11 (57.9)
4 (21.1)
1 (5.3)
10 (47.6)
24 (80)
5 (16.7)
1 (3.3)
17 (56.7)
4 (13.3)
2 (6.7)
12 (40) *Includes RMP, shop and temple priest
^ Some children were prescribed one than one medication
35
4.5.1 Bivariate analysis with Prevalence of diarrhea as the outcome variable
Bivariate analysis was done with the outcome variable i.e the prevalence of diarrhea and the
exposure variable separately for the Banjara/thanda and non-Banjara/village and presented in
table 4.6. It is seen that in the Banjara/thanda the prevalence of diarrhea is related to the type
of house that the child lives in. Children living in semi-pucca house had a higher prevalence
of diarrhea when compared to those in kacha or pucca houses and this difference was
statistically significant. Water location for household use and education of the primary care
giver were not related to the prevalence of diarrhea in the Banjara/thanda. With respect to
the non-Banjara village, none of the three exposure variables were related to the prevalence
of diarrhea.
Table 4.6.Association between the prevalence of diarrhea with water location, type of
house and education of the primary care giver in village and thanda, Gadag District,
Karnataka
Diarrhea
Yes (%)
Diarrhea
No (%)
ꭓ2 p value
Village
Water location
In own dwelling
In own yard/plot
Elsewhere
1 (2.2)
8 (11.9)
5 (10.6)
45 (97.8)
59 (88.1)
42 (89.4)
3.782 0.157
Type of house
Kaccha
Semi-pucca
Pucca
1 (4.8)
6 (10.9)
7 (8.3)
20 (95.2)
49 (89.1)
77 (91.7)
0.602 0.791
Education of primary care
giver
Attended school
Not attended school
11 (8.4)
3 (10.3)
120 (91.6)
26 (89.7)
0.720
Continued….
36
Diarrhea
Yes (%)
Diarrhea
No (%)
ꭓ2 p value
Thanda
Water location
In own dwelling
In own yard/plot
Elsewhere
5 (15.6)
9 (12.7)
7 (12.3)
27 (84.4)
62 (87.3)
50 (87.7)
0.344 0.908
Type of house
Kaccha
Semi-pucca
Pucca
1 (8.3)
10 (29.4)
10 (8.8)
11 (91.7)
24 (70.6)
104 (91.2)
8.591 0.010
Education of primary care
giver
Attended school
Not attended school
13 (15.5)
8 (10.5)
71 (84.5)
68 (89.5)
0.857 0.483
4.5.2 Correlates of facility visited for diarrhea
Fisher’s exact test was done to test the association of the facility visited for diarrhea with
location of residence and education of the primary care giver and the results are presented in
table 4.7. It is seen that the location of residence and education of the primary care giver
were not related to the type of facility from where care was sought for diarrhea.
Table 4.7. Association between the facility visited for diarrhea with the location of
residence and education of primary care giver, Gadag district, Karnataka
Variable Facility visited for diarrhea
Government Private BAMS/RMP ꭓ2 P value
Location of residence
Village
Thanda
1 (9.1)
5 (26.3)
6 (54.5)
8 (42.1)
4 (36.4)
6 (31.6)
1.252 0.621
Education of Primary Care
giver
Attended School
Not attended School
4 (19)
2 (22.2)
9 (42.9)
5 (55.6)
8 (38.1)
2 (22.2)
0.833 0.773
37
4.6 ARI -healthcare seeking
Among the 79 children with ARI 56 (70.9%) had fever along with cough and 9 (11.4%) had
difficulty in breathing or fast breathing or chest-in drawing along with cough. Only 60
(76%) of 79 children were taken to a facility outside the home. The proportion of children
taken to a facility was similar across Banjara/thanda (76.7%) and non-Banjara/village (75%).
Among those who sought care about 33.3 percent of the primary care givers provided some
form of treatment at home before taking the child to the health care facility. The number of
days following which the child was taken to a facility was similar across Banjara/thanda (M=
1.42, SD = 1.27) and non-Banjara/village (M =1.4, SD= 1.42). The overall utilization of
government facility was poor with only 15.2 percent of people in the Banjara/thanda
preferring government facility. More than half the children with ARI in the thanda and
village sought care from Ayurvedic (BAMS) doctors and unqualified providers (RMP).
More than half the children were given antibiotics and 27.1 percent received some kind of
injection for which there was no record or the primary care givers were not aware of what
kind of injection was being administered.
Table 4.8.Distribution of children in village and thanda by health care seeking for ARI
(N = 60), Gadag district, Karnataka
Characteristics Village
[N=27]
n (%)
Thanda
[N=33]
n (%)
Total
[N=60]
n(%)
Treatment at home before
going to the facility
Yes 9 (33.3) 11 (33.3) 20 (33.3)
Choice of facility
Government
Private hospital/clinic
BAMS
Others*
0 (0)
13 (48.2)
8 (29.6)
6 (22.2)
5 (15.2)
8 (24.2)
13 (39.4)
7 (21.2)
5 (8.3)
21 (35)
21 (35)
13 (21.7)
Continued….
38
Characteristics Village
[N=27]
n (%)
Thanda
[N=33]
n (%)
Total
[N=60]
n(%)
Medicines prescribed^
Antibiotics
Others
Unknown pill or syrup
Antibiotic injection
Unknown injection
17 (65.4)
20 (76.9)
3 (11.5)
1 (3.8)
8 (30.8)
16 (48.5)
29 (87.9)
3 (9.1)
2 (6.1)
8 (24.2)
33 (55.9)
49 (83.1)
6 (10.2)
3 (5.1)
16 (27.1) *Includes RMP and shop
^ Some children were prescribed one than one medication
4.6.1 Bivariate analysis with ARI as the outcome variable
Fishers exact test was done to test the association between the outcome variable i.e the
prevalence of ARI and the exposure variable separately for the Banjara/thanda and non-
Banjara/village and the results are presented in table no 4.9. In the thanda and the village-
water location, type of house or the education of the primary care giver was not related to the
prevalence of ARI. The prevalence of ARI did not vary much in households in
Banjara/thanda and non-Banjara/village which had a drinking water source close by or far
away from the house. Similarly the prevalence was similar across the primary care givers
who were educated and those who were not. It also did not differ by the type of house that
the child lives in but children in kaccha house in thanda had higher prevalence whereas the
children in similar housing condition in the village had lower prevalence.
Table 4.9.Association of the prevalence of ARI with water location, type of house and
education of the primary care giver in village and thanda, Gadag district, Karnataka
ARI
Yes (%)
ARI
No (%)
ꭓ2 p value
Village
Water location
In own dwelling
In own yard/plot
Elsewhere
10 (21.7)
16 (23.9)
10 (21.3)
36 (78.3)
51 (76.1)
37 (78.7)
0.129 0.801
Continued….
39
ARI
Yes (%)
ARI
No (%)
ꭓ2 p value
Type of house
Kaccha
Semi-pucca
Pucca
2 (9.5)
17 (30.9)
17 (20.2)
19 (90.5)
38 (69.1)
67 (79.8)
4.284 0.115
Education of primary care
giver
Attended school
Not attended school
28 (22.1)
7 (24.1)
102 (77.9)
22 (75.9)
0.054 0.815
Thanda
Water location
In own dwelling
In own yard/plot
Elsewhere
8 (25)
21 (29.6)
14 (24.6)
24 (75)
50 (70.4)
43 (75.4)
0.476 0.801
Type of house
Kaccha
Semi-pucca
Pucca
5 (41.7)
9 (26.5)
28 (25.4)
7 (58.3)
25 (73.5)
85 (74.6)
1.578 0.496
Education of primary care
giver
Attended school
Not attended school
22 (26.2)
21 (27.6)
62 (73.8)
55 (72.4)
0.042 0.860
4.6.2 Correlates of facility visited for ARI
Fisher’s exact test was used to test the association between the facilities visited for ARI with
location of residence and education of the primary care giver. It was found that location of
residence and the education of the primary care giver were related to the facilities from
where care was sought and this association was statistically significant.
40
Table 4.10.Association between the facility visited for ARI with the location of residence
and education of primary care giver, Gadag district, Karnataka
Variable Facility visited for ARI
Government Private BAMS/RMP ꭓ2 P value
Location of residence
Village
Thanda
0 (0)
5 (15.2)
13 (48.1)
8 (24.2)
14 (51.9)
20 (60.6)
6.509 0.038
Education of Primary Care
giver
Attended School
Not attended School
1 (2.6)
4 (18.2)
19 (50)
2 (9.1)
18 (47.4)
16 (72.7)
12.596 0.001
4.7 Care seeking for Morbidity
Children with ARI and Diarrhea were taken together to estimate the overall morbidity and
this outcome variable was used to test the association with various exposure variables.
4.7.1 Correlates of overall morbidity
Morbidity was not related to the type of house in the Banjara/thanda, water location and
education of the primary care giver in both the thanda and the village. However in the non-
Banjara/village there were more children with morbidity in the semi pucca houses but this
association was not significant at the p<0.05 significance level.
Table 4.11.Association of the prevalence of overall Morbidity with water location, type
of house and education of the primary care giver in village and thanda, Gadag district,
Karnataka
Morbidity
Yes (%)
Morbidity
No (%)
ꭓ2 p value
Village
Water location
In own dwelling
In own yard/plot
Elsewhere
10 (21.7)
23 (34.3)
14 (29.8)
36 (78.3)
44 (65.7)
33 (70.2)
2.089 0.352
Continued….
41
Morbidity
Yes (%)
Morbidity
No (%)
ꭓ2 p value
Type of house
Kaccha
Semi-pucca
Pucca
3 (14.3)
22 (40)
22 (26.2)
18 (85.7)
33 (60)
62 (73.8)
5.708 0.059
Education of primary care
giver
Attended school
Not attended school
38 (29)
9 (31)
93 (71)
20 (69)
0.047 0.828
Thanda
Water location
In own dwelling
In own yard/plot
Elsewhere
12 (37.5)
28 (39.4)
20 (35.1)
20 (62.5)
43 (60.6)
37 (64.9)
0.255 0.911
Type of house
Kaccha
Semi-pucca
Pucca
6 (50)
17 (50)
37 (32.5)
6 (50)
17 (50)
77 (67.5)
4.352 0.121
Education of primary care
giver
Attended school
Not attended school
34 (40.5)
26 (34.2)
50 (59.5)
50 (65.8)
0.668 0.513
4.7.2 Correlates of facility visited for Morbidity
Fisher’s exact test was done to test the association between facilities visited for morbidity
with location of residence and education of primary care giver and it was found that they
were related to the facility from where care was sought and this association is statistically
significant. Primary care givers in the Banjara/thanda utilized government facility and
42
BAMS/RMP providers compared to the non-Banjara/village and there was more utilization
of the private providers by primary care givers in the non-Banjara/village.
Table 4.12.Association between the facility visited for overall Morbidity with the
location of residence and education of primary care giver, Gadag district, Karnataka
Variable Facility visited for Morbidity
Government Private BAMS/RMP ꭓ2 P value
Location of residence
Village
Thanda
1 (2.8)
9 (18.8)
18 (50)
13 (27.1)
17 (47.2)
26 (54.2)
7.505 0.020
Education of Primary Care
giver
Attended School
Not attended School
5 (8.8)
5 (18.5)
26 (45.6)
5 (18.5)
26 (45.6)
17 (63)
6.366 0.041
4.8 Analysis of in-depth interviews
The narratives of discrimination from in-depth interviews were read carefully to identify the
types of discrimination being described. By the method of constant comparison, four distinct
types of perceived discrimination were identified. In addition, by reading through the notes
of the interviews, perceived reasons for discrimination were also identified.
4.8.1 Types of perceived discrimination
Rude Behavior
Rude behavior by health care personnel was the main form of discrimination reported by
informants in the Banjara/thanda and non-Banjara/village. Rude behavior was in the form of
shouting at them or talking without respect. Such behavior was reported from health care
43
settings especially against persons whose dress clearly indicated their caste identity. For
example, a nurse in a scanning center was reported to have shouted at an old lady because her
grandchild passed urine in the waiting area and she wiped it with the child’s wet pant. She
was distinguishable because she was wearing clothes that indicated her caste.
“you people (Banjara’s) are always like this, not clean and always dirty”
-elderly Banjara woman
Such behavior was perceived as insulting by the informant. Rude behavior by field workers
in the community has also been reported. The Accredited Social Health Activist (ASHA) is
reported to have shouted at a pregnant lady in front of her neighbors for demanding antenatal
care services.
“ASHA worker has too much sokku (arrogance) that she will come to the oni (cluster of
houses where people of certain caste reside) and fight in front of others”
- 28 year old woman from the village
This rude behavior resulted in seeking care from alternative sources. Sometimes, women
reported being abused for reasons beyond their control.
They told me that “don’t you have brains, doesn’t your husband have a job, why do you keep
getting pregnant (referring to the 4 children and pregnant with the 5th
)”
- 25 year old Banjara woman
44
Withholding services
Withholding of services could be in the form not providing certain services to the
beneficiaries or in the form of delayed care. This form of reported discrimination was being
practiced by nurses in government hospitals and ASHA workers in the community.
“I’m pregnant with my second child and the ASHA worker has to visit me and I should get
injections and other benefits from her but she doesn’t come home. She visits the houses of a
few people whom she likes. She thinks she has all the authority, because of this I have to go
to a private hospital in Gadag and consult doctors for my check up. We have to pay money
and spend from our pockets”
- 28 year old woman from the village
Individuals who have money and are aware are able to go to a private facility for services
even though it means spending money but for those whose options are limited they have to
look for ways within the existing system to get the care they require. The following two
narratives explain the ways through which pregnant women in non-Banjara/village and
Banjara/thanda had to get their delivery done.
“When I was pregnant, the due date was weeks away and the doctor advised us to get the
delivery done otherwise both the mother and child would not survive. So we got admitted in
the evening, the doctor gave some injections and left. Next day morning he came and asked
us to pay 2500 rupees and after that the delivery would be conducted. Till we paid the
money there was no care, the nurses spoke rudely and did not come for rounds, visits or
provide any care. My father paid 2500 rupees and then normal delivery was conducted by
the doctor. We also had to pay 200 rupees each to the two nurses”
- 23 year old woman from the village
45
“I developed labor pains and my husband took me to the taluka hospital at 8 in the morning.
I was admitted there and they kept me there till 4 in the evening, the nurses there were not
responding when we called them and I was not given any injection or medicine. My husband
went and shouted at them for not providing any care and they immediately referred us to the
district hospital. We had only 1000 rupees with us and we had to borrow extra 3000 rupees
from the ration shop to go to the district hospital. The ambulance driver was not ready to
take us unless we paid 400 rupees which he said was for the petrol. We reached the district
hospital and I delivered my child there and I was taken good care. If we had paid some
money and not shouted at the nurse then my delivery would have been conducted there itself”
- 26 year old Banjara woman
Not spending enough time
This form of discrimination was experienced with physicians. Informants felt that the
physicians were not spending enough time because they were from the village.
“we don’t go to a government hospital because the doctor there will just touch the patient
and send us off, they don’t spend time with us often and they do this to all kind of patients.
These old people (pointing to a dhoti clad elderly gentleman, squatting on the floor) face
discrimination. When they go to a hospital the doctor is aware that he is from the village and
they don’t treat them properly and spend less time”
- 31 year old man from the village
46
Not giving proper information
The information given by the physician was considered to be inadequate or not properly
explained in a way that was understandable.
“the child had fever and cough so we gave him medicines which was at home, it didn’t get
cured so we took him to a children’s hospital in Gadag. There the doctor prescribed
medicines and it didn’t get cured so we went back to him and he prescribed different
medicines, we asked him what was wrong and he didn’t give proper information about what
was happening to the child, so we went to another doctor and he also gave medicines, the
child was a little better but still sick so we went back to him a second time and asked him and
he told us not to give the child anything to eat. How can we not give anything for the child to
eat and starve him? We came back quietly without saying anything. We go there for our
child and for his sake we don’t tell anything. We went to another doctor and he explained
everything to us properly and told us that the child would be alright as he grows. We were
satisfied with his behavior and now we always go to him for treatment”
- 25 year old woman from village
4.8.2 Perceived reasons for discrimination
The main reasons for being discriminated were identified through the interviews. Three
reasons were clearly enunciated and these were related to being poor, wearing distinctive
clothing and poor educational status.
47
Being poor or Poverty
Those who were poor were not able to give money to the providers for services which were
free and were perceived to be discriminated against.
“when she visits people houses they offer chai, biscuit and some money but not all can
provide these things. She only visits a few peoples house whom she likes”.
- 28 year old woman from the village
Wearing distinctive clothing
The clothes that people wear determined whether they were discriminated or not. In case of
older Banjaras they can be easily identified by their distinct clothing.
“my mother is hale mandhi (reffering to people belonging to older generation). Fifteen to
twenty years back all old people in our community used to wear traditional Banjara dress
and they continue to this day unlike the younger generation who do not wear such clothes.
The nurse behaved that way because she could make out that my mother was a Banjara”
- 30 year old Banjara man
Persons wearing western clothing like shirt and trousers compared to those wearing
traditional dhotis are less likely to be discriminated or treated badly.
“the nurses in government don’t treat the people properly and talk rudely, it always happens
to people from our thanda. If a well-dressed person or a person wearing pant and shirt goes
they will treat them properly and others are treated badly”
-23 year old Banjara woman
48
Low educational status
Lack of education was seen as a reason for discrimination.
“education is important, if people are educated they will have value. People like us have not
studied properly (not having higher education) and we cannot speak in front of such
educated people. Village people are like that. We stand with our mouth shut. If in that place
any educated person would have been the doctors would have spoken properly to them and
got the respect they deserve”
- 25 year old woman from village
However a person who is uneducated but is smart is able to escape from those who
discriminate.
“after my wife delivered the nurse there demanded 500 rupees as their fees. I questioned
them asking what kind of fees is that and I demanded them to give me receipt. Since they
didn’t agree for receipt I didn’t give any money. I pretended to call the minister in front of
them. The nurse on hearing this got scared and left the place. People who are uneducated but
smart are able to escape but old people accompanying their daughters don’t know anything
and pay how much ever the nurse demands”
- 32 year old Banjara man
49
CHAPTER 5
DISCUSSION AND CONCLUSIONS
5.1 Summary of key findings
The prevalence of diarrhea, ARI and overall morbidity was more in the Banjara/thandas
compared to the non-Banjara/village. Out of the 320 children studied 107 (33.4%) fell sick.
Among 107 children who were sick 23 (21.5%) did not seek any care outside the home, the
reasons being financial inability to seek care (17.4%) and more than half (69.5%) the primary
giver treated the children with medications that were left over from an earlier episode.
Among the 35 children with diarrhea, 30 sought care from a facility. More than one third of
the primary care givers provided some form of treatment at home before taking them to a
facility. Among those who sought care from a government facility there was higher
proportion of people from the Banjara/thanda. Four-fifths (80%) of the children were
prescribed antibiotics for diarrhea and less than half the children in thanda received unknown
injections compared to the children in the village. Only one child was given ORS for
management of diarrhea. In the Banjara/thanda the type of house was related to the
prevalence of diarrhea with children in semi pucca house having a higher prevalence of
diarrhea. The facility visited for diarrhea was not related to the location of the residence or
the education of the primary caregiver.
Among the 79 children with ARI only 60(76%) were taken to a facility outside the home.
Almost one third of the primary care givers provided some form of treatment at home before
going to the facility. The overall utilization of government facilities was poor with only a
few people from the Banjara/thanda preferring to seek care there. A higher proportion of
50
care givers in the Banjara/thanda utilized BAMS/RMPs and Government providers when
compared to those in the village. The use of antibiotics was high with more than half the sick
children being prescribed antibiotics. Less than one third of the children in both
Banjara/thanda and non-Banjara/village received unknown injections for which there was no
record or the primary care givers were unaware of the kind of injection. The prevalence of
ARI was not related to water location, type of house or the education of the primary care
giver. The facility from where care was sought was related to the location of residence and
education of primary care giver with people in the thanda preferring care from government
facility and BAMS/RMP providers compared to the people in the non/Banjara/village.
Primary care givers who had attended school went to private facilities for seeking care
compared to those who had not attended school who went to government facility and
BAMS/RMP. The findings were similar for overall morbidity.
Discrimination
Findings from the quantitative component suggest that the overall experience of
discrimination was 6% and there was not much difference in the experience of discrimination
between the Banjara/thanda and non-Banjara/village. The type of discrimination faced was
rude behavior, withholding services, not spending enough time and not giving proper
information. However the qualitative analysis revealed that discrimination experienced by
the members of the community, both in the Banjara/thandas and in the non-Banjara/village
was class based and not caste based. The perceived reasons for discrimination were being
poor, clothing and educational status.
51
5.2Diarrhea and its correlates
The overall prevalence of diarrhea in the present study was found to be 10.9 percent which is
slightly higher than the findings from District Level Household Survey- 4 (DLHS-4)(IIPS,
2014) in Gadag district and NFHS-3(IIPS, 2007)for Karnataka but higher compared to a
multi-district study of which Gadag was a part of (Lahariya et al, 2012). The prevalence of
diarrhea was more among the Banjaras (13.1%) compared to the non Banjaras(8.75%) which
is different from the findings of NFHS-3 where the children belonging to the Scheduled
Caste had lower prevalence compared to the Other Backward Caste. The utilization of
facilities outside the home was more with 85.7 percent seeking care which is more than the
estimates of DLHS-4 and NFHS-3. The care seeking was more among the children in the
Banjara/thanda compared to the non-Banjara/village and this is consistent with the findings
of NFHS-3. The utilization of government facilities was much lower and is almost similar to
the study done in Gadag district (Lahariya et al, 2012). Only one child (3.3%) was given
ORS for the management of diarrhea which is very low compared to 40.4 percent and 47
percent in DLHS-4 and NFHS-3. ORS remains the mainstay of treatment for management of
dehydration in diarrhea but in the current study a shift is seen in the management of diarrhea
with increased use of antibiotics, antimotility drugs and injections which are considered
inappropriate treatment for children. Antibiotics is indicated in diarrhea only when there is
blood in the stools (WHO, 2003); however in the current study large proportion of children
who did not have blood in their stool were given antibiotics and unknown injections which
could have been antibiotics. This suggests an inappropriate and irrational use of antibiotics
which can lead to drug resistance and push up the costs of treatment. This practice is similar
to a study done in Delhi (Kotwani et al, 2012). The prescription practices could be influenced
52
by the pressure to deliver faster relief. Most of the primary care givers visited BAMS
doctors and RMP who were practicing modern system of medicine and providing these
inappropriate treatment options.
5.3 ARI and its correlates
The prevalence of ARI was 24.7 percent which was very high compared to previous studies
(IIPS, 2007, 2014; Lahariya et al, 2012). The prevalence of ARI was more among the
children in the Banjara/thanda (26.9%) compared to the non-Banjara/village (22.5%). The
utilization of facilities outside the home was 76 percent which is lesser than the DLHS-4
estimate(IIPS, 2014) but much higher than the study done in Gadag district (Lahariya et al,
2012). Utilization of facilities was same across thanda and village. The utilization of
government facilities for ARI (8.3%) was low compared to other studies (IIPS, 2014;
Lahariya et al, 2012). Among the users of government services all of them were from the
Banjara/thanda. The prescription of antibiotics was high with 48.5 percent in the
Banjara/thanda and 65.4 percent in the non-Banjara/village receiving antibiotics. According
to Integrated Management of Neonatal and Childhood Illness (IMNCI) guidelines antibiotics
are indicated only when the child has cough along with difficulty in breathing or fast
breathing or chest-in drawing (WHO, 2003). In the current study only 11.4 percent of the
children had these symptoms but the proportion of children receiving antibiotics was much
higher which again indicates irrational use of antibiotics in children. The utilization of
BAMS providers and RMP who are unqualified was very high for ARI and this could one of
the reasons for high prescription of antibiotics. The facility visited for ARI was related to the
53
location of residence and education of the primary care giver. Educated people would have
more information regarding the providers and the types of facilities and this would explain
the increased utilization of private facilities among educated people.
The difference in the prevalence of ARI and Diarrhea is not explained by the location of
water source, the type of house or the education of the primary care giver; however type of
house was related to the prevalence of diarrhea in the Banjara/thanda where a higher
prevalence was observed among those residing in semi-pucca houses. The difference in
morbidity could be because of the density i.e number of dwelling per area which was more in
the Banjara/thanda compared to the non-Banjara/village. However this study did not measure
the density of dwellings per unit of area. Antibiotics usage was very high for diarrhea and
ARI. Irrational usage was due to the providers prescribing antibiotics and lack of awareness
and information of antibiotic use among the primary care givers. When a child is prescribed
medicines for sickness and is cured the medicines are stored and are used the next time when
the child falls sick with similar symptoms. This practice was seen in the current study where
close to one third of the primary care givers of children with diarrhea and ARI gave them
medicines which were prescribed previously before taking them to a facility. This can lead
to antibiotic resistance which prolongs the duration of illness and increase costs. The bulk of
government and private healthcare facilities are located in the city of Gadag compared to the
rural areas where the government facilities are Taluka hospitals and PHC’s/CHC’s and
private facilities which are run by qualified medical doctors, BAMS doctors and RMPs.
Shortage and non-availability of doctors in government facilities are the reasons for people
seeking care elsewhere. This huge gap is filled by the BAMS providers and RMPs. The
unqualified providers in Gadag district are referred to as RMPs. They are private providers
54
who offer allopathic curative care without having any medical degree recognized by the
Government of India (George and Iyer, 2013). They practice by setting up clinics in villages
or thandas or by going door to door providing treatment for any ailments in the house. More
people from the Banjara/thanda were going to government facilities or BAMS/RMPs
compared to the non-Banjara/village even though the geographical accessibility of these
facilities were similar across thanda and village. The reason for this could be the relative
poverty of the people in the Banjara/thanda who sought care from facilities which were free
or where they had to pay less for a BAMS provider or pay at a later date in case of RMPs.
The Banjara/thanda people had better housing compared to the village which itself is a result
of the government schemes directed towards them and therefore is not an indicator of
economically better status.
5.4 Self-reported experience of discrimination
The discrimination experienced was class based and not caste based (Acharya, 2010) or
based on religion (Kanday and Tanwar, 2013). There was not much difference in the
reported experience of discrimination between non-Banjara/village and Banjara/thanda but
the forms of discrimination and the providers who discriminated was similar to the studies
done in Rajasthan, Gujarat and Mumbai (Acharya, 2010; Kanday and Tanwar,2013). This
does not mean that discrimination does not exist in the community or it doesn not act as a
barrier in seeking care. It does exist in the community in subtler forms and is evident from
the qualitative analysis. The qualitative analysis identified poverty, clothing and educational
status as the perceived reasons for discrimination.
55
The objective of the study was to describe the pattern of health care utilization for diarrhea
and ARI for children under five years of age and to identify the self-reported forms of
discrimination. Although the utilization was good for diarrhea and poor for ARI for both
thanda and village the treatment being provided was inappropriate for most of the children
with high use of antibiotics. Self-reported discrimination did not come out as a significant
finding but it does exist in the community as evidenced from the qualitative findings.
5.5 Limitations of the study
The index of discrimination tool was not able to capture the discrimination in the community.
The tool was designed to capture the discrimination faced by dalit children in Gujarat and
Rajasthan where the community faced severe discrimination. In the current study the people
in the Banjara/thanda do face discrimination but it may not be as severe as reported in other
places and it could be a subtle form of discrimination which the tool failed to capture.
Multivariate analysis was not done as the predictor variable had multiple distinct categories
which could not be merged and there were cells which had less than 10 cases which would
lead to spurious results.
5.6 Strengths of the study
Findings from the study can be extrapolated to the population of Gadag district. Efforts were
made to verify the health care seeking by going through the prescription slips of the children
who were sick and in cases where the prescription were not available the name of the drugs
56
that were prescribed was noted down. The study was a mixed methods design which was
able to offer a better understanding of the self-reported discrimination other than what could
have been inferred from quantitative findings.
5.7 Conclusions
The study finds that the overall prevalence of morbidity was more among the children in the
Banjara/thanda compared to non-Banjara/village. While health care seeking did not vary by
Banjara/non-Banjara statys, it was equally poor across both communities. The health care
seeking for ARI was poor with only 75 percent of the children being taken to a facility.
Although there was not much difference in the utilization of services; differences in the
Banjara/thanda and non-Banjaravillage were seen for the facilities from where care was
sought for both ARI and diarrhea. There was increased utilization of government and
BAMS/RMP providers in the thanda whereas the utilization of private providers was more
among those in the village. Care when sought and obtained was often inappropriate with the
excessive use of antibiotics for both diarrhea and ARI even when it is not indicated. This has
the potential to increase antibiotic resistance in this vulnerable population. The choice of
facility visited may be shaped by the socioeconomic status and class based discrimination,
however more specific tools are needed to capture this. Future studies are needed to look
into power relations within communities and identify the vulnerable groups in each context
and study the health care seeking and the contribution of class based discrimination in
restricting access to health care.
57
5.8 Policy Implications
The government needs to take measures to strengthen the public sector health facilities by
identifying the problems with each facility and take measures to correct them so that there is
increased utilization by the public. Interventions are needed to educate the communities
about appropriate use of antibiotics and among the providers so that antibiotics are prescribed
only when indicated. Cracking down on RMPs will lead to them emerging in a different
form or place and instead efforts must be made to train these providers on the lines of IMNCI
to provide basic care in the community.
58
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Information sheet
I am Bevin Vinay Kumar V N, student of Master in Public Health (MPH) at AchuthaMenon
Center for Health Science Studies (AMCHSS), Sree Chitra Tirunal Institute for Medical
Sciences and Technology (SCTIMST). As a part of my dissertation I am doing a study titled
“Access to health care among under five children in the Banjara community, Karnataka”. This
study is being done under the supervision of Dr. Mala Ramanathan, Additional Professor,
AMCHSS, SCTIMST.
I am undertaking this study to understand the pattern of health care seeking for childhood illness,
the difficulties faced by people in seeking care and also the discrimination faced by them in a
health facility. Four hundred children and their parents would be recruited randomly in this study
across different thandas and villages in Gadag district.
If you agree to participate in the study then you would be required to answer a set of questions.
This would take about 20 to 30 minutes. Your participation in this study will not be of any direct
benefit to you but it would help to find out the difficulties faced by your community in seeking
health care. Participation in the study is voluntary will not harm you in any way. The information
shared by you would be kept confidential and would be used for research purpose. Only two
persons, myself and my guide would have access to this information. Your individual identity
would never be shared with anyone. You are free to refuse to answer any of the questions and
can withdraw from the interview at any point of time and there would be no penalty for the same.
If you have any clarifications regarding the study you can contact me or Dr Mala Ramanathan,
member-secretary of the Institute Ethics Committee of SCTIMST.
Researcher
Bevin Vinay Kumar V N
MPH Scholar
AMCHSS, SCTIMST
Contact number: 9886482006
E-mail id: [email protected]
Guide& Member Secretary, IEC, SCTIMST
Dr. Mala Ramanathan
Additional Professor
AMCHSS, SCTIMST
Contact number: 0471- 2524234
E-mail id: [email protected]
Consent Form
I, ____________________________________________, aged ___ ___years declare that
I have read and understood the information sheet for the study and have had the opportunity to as
questions [ ]
I understand that the participation in this study is voluntary and that I’m free to withdraw at any
time and without giving any reasons [ ]
I agree not to restrict the use of any data or results that arise from this study provided such a use
is only for scientific purpose(s) [ ]
I agree to take part in the study [ ]
Place: ........................... ID: ...................................
Date: ........................... Signature: ............................................
If the Participant is illiterate:
Name of Witness: ............................................
Signature of witness: ............................................
Signature of Researcher: ............................................
Questionnaire
Access to healthcare among under five children in the Banjara
community, Karnataka
Id: Thanda/Village:
Date of interview:
1 Primary Care
Giver
1.1 Age In which month and year were
you born?
1.2 Educational status Have you ever attended school 1. Yes 2. No
If “Yes” how many years of
schooling did you complete?
(What is the highest standard you
completed)
1.3 Autonomy (wrt
seeking health care
for the child)
Who takes the decision regarding
seeking care outside the house for
the child’s illness?
1. Mother
2. Father
3. Father-in-law
4. Mother-in-law
5. Don’t Know
6. Others_________
2. Relationship to
the child
What is your relationship to the
child?
1. Mother
2. Father
3. Grandmother
4. Grandfather
5. Aunt
6. Others_______
3. Age of the child How old was the child on his/her
last birthday?
4. Sex of the child Is the child a boy or a girl? 1. Male
2. Female
5. Economic status*
5.1 Sanitation
facility
What kind of toilet facility do
members of your household
usually use?
1. Flush or Pour flush toilet
2. Pit Latrine
3. Twin pit/ composting Toilet
4. Dry Toilet
5. No facility/ uses open
space/ field
6. Other________
5.2 Type of house Observe the type of house 1. Kachha
2. Semi-pucca
3. Pucca
5.3 Place for
cooking
Is the cooking usually done in the
house, in a separate building or
outdoors?
1. In the house
2. In a separate building
3. Outdoors
4. Others_____________
5.4 Means of
transport
Does your household have: 1. Motorcycle or Scooter
2. Car
3. Animal drawn cart
4. Bicycle
5. None of the above
5.5 Farm Animals Does your household own any of
the following animals:
1. Cows/Bulls/Buffaloes
2. Horses/Donkeys/Mules
3. Goats
4. Sheep
5. Chickens/Ducks
5.6 Drinking water a. Where is the water source
located
1. In own dwelling
2. In own yard/plot
3. Elsewhere
b. How long does it take to
go there, get water and
come back in one trip?
1. Minutes______
2. On the premises
3. Don’t Know
5.7 BPL Card Do you have a BPL card? 1. Yes 2. No
6.
Religion
What is the religion of the head
of the household?
1. Hindu
2. Muslim
3. Christian
4. No Religion
5. Others__________
7. Caste to which
the child
belongs to
What is the Caste/Tribe that the
head of the household belong to?
1. SC
2. ST
3. OBC
4. None of them
5. Others_____________
*5.1 to 5.7 will be used to compute wealth index
8. Discrimination Sl
No Questions Response
8.1 To your knowledge,
have people in this
community been treated
rudely or made to feel
bad during their visit to
any health care facility?
1. Yes 2. No
8.2 Did you ever
experience a sense of
being treated badly or
with disrespect when
compared to the others
when you visited a
health care facility?
1. Yes 2. No
End if the response in 2 is “No” for both 1 and 2 and go to Q10. If the respondent has said “Yes”, to
either of the two questions, continue.
8.3 If “Yes” then in which
facility did you
experience this:
1. Government health facility
2. Private facility
3. NGO/Trust hospital
4. Others________________
8.4 Where
within the
facility did
you get
such a
feeling
1. Registration counter
2. Waiting outside the health care providers
chamber
3. Interaction with the health care provider
4. Pharmacy
5. X-ray or Laboratory investigations
6. Procedure or Dressing room
7. Others________________
Y N
Y N
Y N
Y N
Y N
Y N
Y N
I’m going to ask a few questions about your experiences at the health care facility. Please respond to these
on the basis of the facility that you remember the most.
Which of the four types of the facility was this: Government/Private/NGO-Trust /others
Sl
No Questions Yes No
Often Occasionally
Registration Counter
Have any of the following things happened to you at the registration counter. Please tell me which
response suits your experience. (Yes,often-3, Yes,occasionally-2, No,never-1)
8.5.1 The clerical staff at
registration counter
spoke rudely or used
derogatory words
while speaking to me
8.5.2 Other fellow patients
spoke rudely or
derogatorily to me
while waiting in the
registration counter
8.5.3 Other fellow patients
were given preference
over me by the
clerical staff at the
registration counter
8.5.4 Other fellow patients
waiting in the Q along
with me pushed me
aside to get the
registration done
Waiting to see the Doctor
Have any of the following things happened to you while waiting to see the Doctor
8.6.1 I have been forced to
make way for a
person to seek
consultation when it
was actually my turn
8.6.2 The peon/person
outside the chamber
spoke rudely or used
derogatory words
while speaking to me
8.6.3 Other fellow patients
were not willing to sit
next to me while I
was waiting to see the
Doctor
Consultation Room
Have any of the following things happened to you while interacting with the Doctor
8.7.1 The doctor spoke
rudely or used
derogatory words
while speaking to me
8.7.2 The doctor’s ’s touch
was rough and not
kind
8.7.3 The doctor avoided
touching during
examination
8.7.4 The doctor did not
spend as much time
with me as he/she did
for others
8.7.5 The doctor did not
give me as much
information about my
health condition as he
did to others
Dispensing of Medicine
Have any of the following things happened to you while getting your medicines (Pharmacy)
8.8.1 The person dispensing
medicines spoke
rudely or used
derogatory words
while speaking to me
8.8.2 The person dispensing
medicines did not
give the medicines in
my hand but left it on
the counter for me to
take it but gave it in
the hand to others
8.8.3 I am made to wait
longer to get the
medicines when
compared to others
Pathological test/X –ray
Have any of the following things happened to you while getting a X-ray or during laboratory
investigations
8.9.1 The technician spoke
rudely or used
derogatory words
while speaking to me
8.9.2 I was made to wait for
long to get my tests
done when compared
to others
Procedure/Dressing room
Have any of the following things happened to you while getting an injection or while getting your wound
dressed
8.10.1 The nurse/nursing
assistant spoke
rudely or used
derogatory words
while speaking to
me
8.10.2 The nurse/nursing
technician avoided
touching during
examination
8.10.3 The nurse/nursing
assistant’s touch
was rough and not
kind
8.10.4 I am made to wait
for long to get the
procedure done
when compared to
others
8.10.5 The nurse/nursing
technician spoke
about me or made
fun of my condition
to other coworker in
front of me
Others (if applicable)
Have any of the following things happened to you _________________________
9. Preferred treatment
provider for people
in this area
If the child had Diarrhea
where would you take him/her
for care?
1. Government hospital
2. Private Hospital
3. Private clinic
4. Pharmacy
5. Traditional healer
6. Vaidya/Hakim/Homeopath
7. Others______________
If the child had ARI where
would you take him/her for
care?
1. Government hospital
2. Private Hospital
3. Private clinic
4. Pharmacy
5. Traditional healer
6. Vaidya/Hakim/Homeopath
7. Others______________
10. Child with
Diarrhea/ARI in
the last two
weeks
Did the child have Diarrhea in
the last two weeks
1. Yes
2. No
Did the child have ARI in the
last two weeks
1. Yes
2. No
8.11.1 The _________
assistant spoke
rudely or used
derogatory words
while speaking to
me
8.11.2 The _________
avoided touching
me during
examination
8.11.3 The _________
touch was rough and
not kind
8.11.4 I am made to wait
for long to get the
procedure done
when compared to
others
8.11.5 The ________
spoke about me or
made fun of my
condition to other
coworker in front of
me.
If “Yes” for both Diarrhea/ARI or Diarrhea or ARI then proceed to 12, if “No” for both then
thank them for their time and end the interview.
11. If “Yes” for Diarrhea then was there
any blood in the stools?
1. Yes
2. No
If “Yes” for ARI then he/she had any of the following
Cough 1. Yes 2.
No
Difficult breathing 1. Yes 2.
No
Fast breathing 1. Yes 2.
No
Chest-in- drawing 1. Yes 2.
No
Fever 1. Yes 2.
No
Loss of Consciousness 1. Yes 2.
No
12. How long ago did the Diarrhea or
Respiratory illness start?
Days_______
Weeks_______
13. Did you seek medical care for the child
outside the home?
1. Yes 2.
No
If “Yes” go to Q15, if “No” then proceed to next question
14. Reasons for not
seeking care
outside the home
If you did not seek care outside your
home, what were the reasons? (Multiple
responses possible)
1. Clinic/facility too far from
the house
2. Unable to find transport
3. Cost of travel too high
4. Cost of treatment too high
5. other children at home
would be left alone
6. Loss of wages
7. Treated the child at home
8. Others_________
After answering this question go to question 19
15. Delay in seeking
care If yes then how many days after the
beginning of diarrhea/cough did you
first go to the facility
15.1 Date of onset of cough/diarrhea
15.2 Approximate time when the symptoms
were noticed
15.3 Date when taken to the health facility
15.4 Approximate time of reaching the
facility
16 Treatment at
home Did you provide any treatment at home
before reaching the facility?
1. Yes 2.
No
16.1 If yes then could you please list the
treatment or treatments in order from the
onset of diarrhea or cough till you decide
to seek care
1st
2nd
3rd
17 Choice of
facility Where did you seek advice or treatment
for diarrhea or ARI?
1. Public Medical Sector
1.1Gov/Municipal Hospital
1.2 Gov Dispensary
1.3 PHC
1.4 CHC/Rural hospital
1.5 Subcenter/ANM
1.6 Gov Mobile clinic
1.7 Anganwadi/ICDS center
1.8ASHA
1.9 Other
2.Private Medical Sector
2.1 Private Hospital
2.2 Pvt Doctor/Clinic
2.3 Pvt Paramedic
2.4
Vaidya/Hakim/Homeopath
2.5 Traditional Healer
2.6 Pharmacy/Drugstore
2.7 Other_____________
3. NGO/Trust/Clinic
4. Others
4.1 Shop
4.2 Friends/Relative
4.3 Others__________
18 Was anything given to treat the diarrhea? 1. Yes 2. No 3.
Don’t know
Was anything given to treat the ARI? 1. Yes 2. No 3.
Don’t know
If “yes” then go to 18.1 or 18.2, if “no” or “Don’t know” skip to 20
18.1 What was given to treat the diarrhea?
(Multiple responses possible)
Pill or Syrup
1. Antibiotic
2. Antimotility
3. Zinc
4. Others(Other than
those mentioned
above)
5. Unknown Pill or
syrup
Injection
6. Antibiotic
7. Non-Antibiotic
8. Unknown Injection
9. Intravenous
10. Home remedy or
herbal medicine
11. Others___________
__
18.2 What was given to treat ARI?
(Multiple responses possible)
Pill or Syrup
1. Antibiotic
2. Others__________
3. Unknown Pill or
syrup
Injection
4. Antibiotic
5. Non-Antibiotic
6. Unknown Injection
7. Intravenous
8. Home remedy or
herbal medicine
9. Others___________
__
19 Reasons for
taking the child
to this facility
What was the reason for taking the child
to this facility for treatment?
Thank the respondent for their time and end the interview
1
Qualitative Component
In-depth Interview guidelines
I’m trying to find out what you did when your child was sick, what kind of treatment you
used to treat your child when he/she was ill and your experiences with the health care
facility.
1. What were the symptoms that caused you to become alert that your child was sick?
When did this happen and what did you do to cure the child?
2. Did you provide any treatment at home?
3. What else did you do? (Visit a local health provider or someone else?)
4. Are there any other providers to whom you can go to? Who are they and why did you
select this particular one? Have you ever used any other providers?
5. What kind of problems have you faced at these providers? Are these problems the
same or are there any differences in your experiences?
6. Some people have reported being treated badly in the hospital because of their caste.
Have you ever experienced any behavior directed at you that made you feel
demeaned either because of your caste or any other reason? If so, what had happened
– can you describe the incident?
7. How did it make you feel? What did you do about it? Could you do anything to
correct this?
8. Did you seek anyone’s help about this event(s)? How often do you experience this
kind of behavior elsewhere (other than the health care setting)?
Leave taking: Is there anything about your experiences in the hospitals here in your
community you would like to add?
Thank you.
ಆಚೂತ ಮೇನ ೂೇನ್ ಸ ೆಂಟರ್ ಫಾರ್ ಹ ೇಲ್ತ ್ಸ ೈನ್್ ಸ್ಟಡೇಸ್
ಸ್ರೇ ಚಿತರ ತಿರುನಾಳ್ ಇನ್ಸ್್ಿಟೂೂಟ್ ಫಾರ್ ಮಡಕಲ್ತ ಸ ೈನ್್ಸ್ ಅೆಂಡ್ ಟ ಕ್ಾಾಲಜೇ, ಟ ೈವೆಂಡ್ರಮ್-695011
ಮಾಹಿತಿ ಹಾಳ ೆ
ನ್ಮಸಾಾರ, ನಾನ್ು ಬ ವಿನ್ ವಿನ್ಯ್ ಕುಮಾರ್ ವಿೇ. ಎನ್, ಮಾಸ್ಟರ್ ಆಫ್ ಪಬ್ಲಿಕ್ ಹ ಲ್ತ್ ಡಗ್ರೇ, ಆಚೂತ ಮೇನ ೂೇನ್ ಸ ೆಂಟರ್ ಫಾರ್ ಹ ೇಲ್ತ ್ಸ ೈನ್್ ಸ್ಟಡೇಸ್, ಸ್ರೇ ಚಿತರ ತಿರುನಾಳ್ ಇನ್ಸ್್ಿಟೂೂಟ್ ಫಾರ್ ಮಡಕಲ್ತ ಸ ೈನ್್ಸ್ ಅೆಂಡ್ ಟ ಕ್ಾಾಲಜೇಯಲ್ಲ ಿಅಧ್ೂಯನ್ ಮಾಡ್ುತಿ್ಧ ೇನ . ನ್ನ್ಾ ಆಧ್ೂಯನ್ಧ್ ಬಾಘವಾಗ್ “ಕನಾಾಟಕದ ಬೆಂಜಾರಾ ಸ್ಮುದಾಯಧ್, ಐದು ವರ್ಾದ ಕ್ ಳಗ ಮಕಾಳ ಅಡಯಲಿ್ಲ ಆರ ೂೇಗ್ೂ ಪರವ ೇಶ” ಸ್ೆಂಶ ೇದನ ಮಾಡ್ುವ ನ್ು. ಈ ಅದೂಯನ್ವು ಡಾ ಮಾಲಾ ರಾಮನಾಥನ್, ಹ ಕುಾವರಿ ಪ್ರರಫ ಸ್ರ್, ಏ.ಎೆಂ.ಸ್.ಏಚ್.ಎಸ್.ಎಸ್ ,
ಎಸ್.ಸ್ೇ.ಟಿ.ಐ.ಮ್.ಸ್.ಟಿ ಮೇಲ್ಲಿಚಾರಣ ಯಲ್ಲ ಿಮಾಡ್ಲಾಗ್ುತಿ್ದ . ನಾನ್ು ಬಾಲೂದ ಅನಾರ ೂೇಗ್ೂದ, ಕ್ಾಳಜ ಮತು ್ಆರ ೂೇಗ್ೂ ಸೌಲಭ್ೂ ಅವುಗ್ಳನ್ುಾ ಎದುರಿಸ್ುವ ತಾರತಮೂದ ಕ್ ೂೇರುತಿ್ರುವ ಜನ್ರು ಎದುರಿಸ್ದ ತ ೂೆಂದರ ಗ್ಳನ್ುಾ ಕ್ ೂೇರಿ ಆರ ೂೇಗ್ೂ ಮಾದರಿಯನ್ುಾ ಅಥಾಮಾಡಕ್ ೂಳಳಲು ಈ ಅಧ್ೂಯನ್ ಕ್ ೈಗ ೂಳಳಳತಿ್ದ ನ . ನಾನ್ೂರು ಮಕಾಳಳ ಮತು ್ಅವರ ಪಾಲಕರು ಗ್ದಗ್ ಜಲ ಿಯ ವಿವಿಧ್ ತಾೆಂಡ್ ಮತು ್ಹಳ್ಳಳಗ್ಳಲ್ಲ ಿಈ ಅಧ್ೂಯನ್ದಲಿ್ಲ ಯಾದೃಚಿಕಿವಾಗ್ ನ ೇಮಕ ಮಾಡ್ಲಾಗ್ದ . ನ್ಸ್ೇವು ಅಧ್ೂಯನ್ದಲಿ್ಲ ಬಾಗ್ವಹಿಸ್ುವುದಾದರ ಕ್ ಲವು ಪರಶ ಾಗ್ಳನ್ುಾ ಉತ್ರಿಸ್ ಅಗ್ತೂವಿದ . ಈ ಬಗ ೆ20 ರಿೆಂದ 30 ನ್ಸ್ಮಿರ್ ತ ಗ ದುಕ್ ೂಳಳಳತದ . ಈ ಅಧ್ೂಯನ್ದೆಂದ ನ್ಸ್ೇವು ಯಾವುದ ೇ ನ ೇರ ಲಾಭ್ದ ಸಾಧ್ೂವಿಲ ಿ
ಆದರ ಆರ ೂೇಗ್ೂ ಚಿಕಿತ ್ ಪಡ ಯಲು ನ್ಸ್ಮಮ ಸ್ಮುದಾಯದಲ್ಲ ಿಎದುರಿಸ್ುವ ತ ೂೆಂದರ ಗ್ಳನ್ುಾ ಕೆಂಡ್ುಹಿಡಯಲು ಸ್ಹಾಯ ಎೆಂದು . ಅಧ್ೂಯನ್ದಲಿ್ಲ ಪಾಲ ೂೆಳಳಳವಿಕ್ ಯನ್ುಾ ಯಾವುದ ೇ ರಿೇತಿಯಲ್ಲ ಿನ್ಸ್ಮಗ ಹಾನ್ಸ್ ಮಾಡ್ುವುದಲ.ಿ ನ್ಸ್ೇವು ಹೆಂಚಿಕ್ ೂೆಂಡರುವ ಮಾಹಿತಿ ಗೌಪೂವಾಗ್
ಇಡ್ಲಾಗ್ುತ್ದ ಮತು ್ಸ್ೆಂಶ ೇಧ್ನ ಉದ ದೇಶಕ್ಾಾಗ್ ಬಳಸ್ಲಾಗ್ುತ್ದ . ಕ್ ೇವಲ ಎರಡ್ು ವೂಕಿ್ಗ್ಳಳ , ನಾನ್ು ಮತು ್ನ್ನ್ಾ ಮಾಗ್ಾದರ್ಶಾ ಈ
ಮಾಹಿತಿಯ ಪರವ ೇಶವನ್ುಾ ಹ ೂೆಂದರುತ ್ೇವ . ನ್ಸ್ಮಮ ವ ೈಯಕಿಕ್ ಗ್ುರುತನ್ುಾ ಹೆಂಚಿಕ್ ೂಳಳಲಾಗ್ುವುದಲ ಿಎೆಂದು, ನ್ಸ್ೇವು ಪರಶ ಾಗ್ಳ್ಳಗ , ಯಾವುದ ೇ ಉತ್ರವನ್ುಾ ನ್ಸ್ರಾಕರಿಸ್ಬಹುದು. ಯಾವುದ ೇ ಸ್ಮಯ ಹೆಂತದ ಸ್ೆಂದಶಾನ್ದಲ್ಲ ಿನ್ಸ್ಮಮ ಪಾಲನ್ುಾ ಹಿೆಂಪಡ ಯಬಹುದಾಗ್ದ ಮತು ್ಅದ ೇ ಯಾವುದ ೇ ದೆಂಡ್ ಇಲಿ. ನ್ಸ್ೇವು ಅಧ್ೂಯನ್ ಬಗ ೆಯಾವುದ ೇ ಸ್ಪಷ್ಟೇಕರಣ ಹ ೂೆಂದದದರ ನ್ಸ್ೇವು ನ್ನ್ಗ ಅಥವಾ ಡಾ ಮಾಲಾ ರಾಮನಾಥನ್ ,
ಎಸ್.ಸ್ೇ.ಟಿ.ಐ.ಮ್.ಸ್.ಟಿ ಇನ್ಸ್್ಿಟೂೂಟ್ ಎಥಿಕ್್ ಸ್ಮಿತಿಯ ಸ್ದಸ್ೂ - ಕ್ಾಯಾದರ್ಶಾ ಸ್ೆಂಪಕಿಾಸ್ಬಹುದು .
ಸ್ೆಂಶ ೇಧ್ಕ
ಬ ವಿನ್ ವಿನ್ಯ್ ಕುಮಾರ್ ವಿ ಎನ್
ಎೆಂ.ಪೇ.ಹ ೇಚ್
ಏ.ಎೆಂ.ಸ್.ಏಚ್.ಎಸ್.ಎಸ್ , ಎಸ್.ಸ್ೇ.ಟಿ.ಐ.ಮ್.ಸ್.ಟಿ
ಸ್ೆಂಪಕಾ ಸ್ೆಂಖ್ ೂ : 9886482006
ಮೇಲ್ತ ಐಡ : [email protected]
ಗ ೈಡ್ & ಸ್ದಸ್ೂ ಕ್ಾಯಾದರ್ಶಾ , ಐಇಸ್ , ಎಸ್.ಸ್ೇ.ಟಿ.ಐ.ಮ್.ಸ್.ಟಿ
ಡಾ ಮಾಲಾ ರಾಮನಾಥನ್
ಹ ಚುುವರಿ ಪ್ರರಫ ಸ್ರ್
ಏ.ಎೆಂ.ಸ್.ಏಚ್.ಎಸ್.ಎಸ್ , ಎಸ್.ಸ್ೇ.ಟಿ.ಐ.ಮ್.ಸ್.ಟಿ
ಸ್ೆಂಪಕಾ ಸ್ೆಂಖ್ ೂ : 0471- 2524234
ಮೇಲ್ತ ಐಡ : [email protected]
ಸಮ್ಮತಿ ಪತ್ರ
ನಾನ್ು , ___________________________________ , ವಯಸ್್ನ್ ___ ___ ವರ್ಾಗ್ಳ ಎೆಂದು ಘೂೇಷ್ಸ್ಲು ನಾನ್ು ಓದಲು ಮತು ್ಅಧ್ೂಯನ್ ಮಾಹಿತಿ ಹಾಳ ಅಥಾ ಮತು ್ಪರಶ ಾಗ್ಳನ್ುಾ ಕ್ ೇಳಲು ಅವಕ್ಾಶ ನ್ಸ್ೇಡ್ಲಾಯಿತು [ ]
ನಾನ್ು ಈ ಅಧ್ೂಯನ್ದಲಿ್ಲ ಪಾಲ ೂಳೆಳಳವಿಕ್ ಯನ್ುಾ ಸ್ಿಯೆಂಪ ರೇರಿತ ಎೆಂದು ಅಥಾ ಮತು ್ನಾನ್ು ಯಾವುದ ೇ ಸ್ಮಯದಲಿ್ಲ ಮತು ್ಯಾವುದ ೇ
ಕ್ಾರಣ ನ್ಸ್ೇಡ್ದ ಹಿೆಂದಕ್ ಾ ತ ಗ ದುಕ್ ೂಳಳಬಹುದು [ ]
ನಾನ್ು ಈ ಅಧ್ೂಯನ್ದೆಂದ ಉದಭವಿಸ್ುವ ಯಾವುದ ೇ ಡ ೇಟಾ ಅಥವಾ ಬಳಸ್ುವುದರಿೆಂದಾಗ್ ನ್ಸ್ಬಾೆಂಧಿಸ್ಲು ಇೆಂತಹ ಬಳಕ್ ಯು ವ ೈಜ್ಞಾನ್ಸ್ಕ
ಉದ ದೇಶಕ್ಾಾಗ್ ಮಾತರ ಒದಗ್ಸ್ಲು ಒಪುಪತ ್ೇನ [ ]
ನಾನ್ು ಅಧ್ೂಯನ್ದಲ್ಲಿ ಭಾಗ್ವಹಿಸ್ಲು ಒಪಪಕ್ ೂಳಳಳತ ೇ್ನ [ ]
ಸ್ಥಳ………………………………….. ಐಡ………………………………………….. ದನಾೆಂಕ………………………………………. ಸ್ಹಿ…………………………………………..
ಪಾಲ ೂಳೆಳಳವವರು ಅನ್ಕ್ಷರಸ್ಥ ವಾಗ್ದದರ : ಸಾಕ್ಷಿಯ ಹ ಸ್ರು………………………………………………… ಸಾಕ್ಷಿಯ ಸ್ಹಿ……………………………… ಸ್ೆಂಶ ೇಧ್ಕ ಸ್ಹಿ……………………………………..
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3. w½¢gÀĪÀÅ¢®è.
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1) ºËzÀÄ 2) E®è
6 zsÀªÀÄð ªÀÄ£É0iÀÄ 0iÀÄdªÀiÁ£À 0iÀiÁªÀ
zsÀªÀÄðPÉÌ
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1. »AzÀÄ
2. ªÀÄĹèA
3. Qæ²Ñ0iÀÄ£ï
4. 0iÀiÁªÀzÉà zsÀªÀÄðPÉÌ ¸ÉÃjgÀĪÀÅ¢®è
5. EvÀgÉÃ ____________
7 ªÀÄUÀÄ«£À eÁw ªÀÄUÀÄ 0iÀiÁªÀ
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1. ¥Àj²µÀÖ eÁw (J¸ï.¹)
2. ¥Àj²µÀÖ d£ÁAUÀ (J¸ï.n.)
3. »AzÀĽzÀ eÁw (N.©.¹.)
4. 0iÀiÁªÀÅzÀÆ E®è
5. EvÀgÉÃ _________
8 ¸ÁªÀiÁfPÀ vÁgÀvÀªÀÄå CxÀªÁ ¨sÉÃzsÀ-¨sÁªÀ
C.£ÀA ¥Àæ±ÉßUÀ¼ÀÄ ¥ÀævÀÄåvÀÛgÀUÀ¼ÀÄ
8.1 ¤ªÀÄä C£ÀĨsÀªÀPÉÌ ¹Ã«ÄvÀªÁzÀAvÉ ¤ªÀÄä
¸ÀªÀÄƺÀzÀªÀgÀÄ JAzÁzÀgÀÆ DgÉÆÃUÀå ¸ÀA¸ÉÜ
CxÀªÁ D¸ÀàvÉæUÀ¼À°è ¸ÁªÀiÁfPÀ
¸ÁÜ£ÀªÀiÁ£ÀUÉƼÀ¥ÀlÄÖ zËdð£ÀåQÌÃqÁVzÁÝgÁ ?
1. ºËzÀÄ 2. E®è
8.2 ¤ÃªÀÅ ªÉÊ0iÀÄQÛPÀªÁV DgÉÆÃUÀå ¸ÀA¸ÉÜ CxÀªÁ
D¸ÀàvÉæUÉ ºÉÆÃUÀĪÁUÀ eÁwUÀvÀ vÁgÀvÀªÀÄå
CxÀªÁ ¨ÉÃzsÀ¨sÁªÀPÉÌ M¼ÀUÁV¢ÝÃgÁ ?
1. ºËzÀÄ 2. E®è
¥Àæ±Éß 8.1 ªÀÄvÀÄÛ 8.2 gÀ°è ºËzÀÄ JAzÁzÀgÉ ªÀÄÄAzÀĪÀgɹ E®èªÁzÀgÉ £ÉÃgÀªÁV ¥Àæ±Éß 9 PÉÌ
ºÉÆÃVj. End if the response in 2 is “No” for both 1 and 2 and go to Q9. If the respondent has said
“Yes”, to either of the two questions, continue.
8.3 ºËzÉAzÀgÉ 0iÀiÁªÀ DgÉÆÃUÀå PÉÃAzÀæzÀ°è ¤ÃªÀÅ
F vÁgÀvÀªÀÄå/¨ÉÃzsÀ¨sÁªÀªÀ£ÀÄß C£ÀĨsÀ«¹¢ÝÃj
?
1. ¸ÀgÀPÁj CgÉÆÃUÀå ¸ÀA¸ÉÜ
2. SÁ¸ÀV DgÉÆÃUÀå ¸ÀA¸ÉÜ
3. J£ï.f.N. CxÀªÁ ¸ÁA¸ÁܤPÀ D¸ÀàvÉæ
4. EvÀgÉÃ
-5-
8.4 DgÉÆÃUÀå PÉÃAzÀæ
D¸ÀàvÉæ0iÀÄ 0iÀiÁªÀ
¨sÁUÀzÀ°è ¤ªÀÄUÉ F
1. £ÉÆÃAzÀt «¨sÁUÀ
2. ªÉÊzÀågÀ PÉÆoÀr0iÀÄ ºÉÆgÀUÀqÉ
¸Á®Ä ¤AwgÀĪÁUÀ
ºËzÀÄ E®è
ºËzÀÄ E®è
¨sÁªÀ£É PÀAqÀÄ §A¢vÀÄ 3. ªÉÊzÀågÉÆA¢UÉ ¸ÀªÀiÁ¯ÉÆÃZÀ£É
ªÀiÁqÀĪÁUÀ
4. OµÀzÁ®0iÀÄzÀ°è
5. JPÀìgÉ «¨sÁUÀ CxÀªÁ gÀPÀÛ
vÀ¥Á¸ÀuÁ PÉÃAzÀæzÀ°è
6. aQvÁì PÉÆoÀr CxÀªÁ
qÉæ¹ìAUÀ PÉÆoÀr0iÀÄ°è
7. EvÀgÉÃ
ºËzÀÄ E®è
ºËzÀÄ E®è
ºËzÀÄ E®è
ºËzÀÄ E®è
ºËzÀÄ E®è
£Á£ÀÄ ¤ªÀÄUÉ DgÉÆÃUÀå ¸ÀA¸ÉÜ CxÀªÁ zÀªÁSÁ£É0iÀÄ°è ¤ªÀÄä C£ÀĨsÀªÀzÀ §UÉÎ PÉ®ªÉÇAzÀÄ ¥Àæ±ÉßUÀ¼À£ÀÄß
PÉüÀÄvÉÛÃ£É ¤ªÀÄUÉ Cwà ºÉZÁÑV £É£À¦gÀĪÀ ¸ÀA¸ÉÜ CxÀªÁ zÀªÁSÁ£É ºÁUÀÆ D¸ÀàvÉæ0iÀÄ §UÉÎ «ªÀj¹ ?
F ªÀÄÄAzÉ PÁt¹gÀĪÀ 0iÀiÁªÀ DgÉÆÃUÀå ¸Ë®¨sÀåUÀ¼À°è EzÀÄ MAzÀÄ DVvÀÄÛ ?
¸ÀgÀPÁj / SÁ¸ÀV / J£ï.f.N. / ¸ÁªÀiÁfPÀ ¸ÀA¸ÉÜ / EvÀgÉÃ
C.£ÀA ¥Àæ±ÉßUÀ¼ÀÄ ºËzÀÄ E®è
0iÀiÁªÁUÀ®Æ DUÁUÀ
£ÉÆÃAzÀt «¨sÁUÀzÀ°è F WÀl£É £ÀqÉ¢zÀÝgÉ, zÀ0iÀĪÀiÁr ¤ªÀÄUÉ 0iÀiÁªÀÅzÀÄ ¸ÀÆPÀÛªÁVzÉ0iÉÄà CzÀ£ÀÄß
UÀÄgÀÄw¹ (ºËzÀÄ, 0iÀiÁªÁUÀ®Æ-3, ºËzÀÄ DUÁUÀ-2, E®è-1)
8.5.1 £ÉÆÃAzÀt PÉÃAzÀæzÀ UÀĪÀiÁ¸ÀÛ
¤ªÉÆäA¢UÉ CªÁZÀå
±À§ÝUÀ¼ÉÆA¢UÉ
ªÀiÁvÀ£ÁrzÁÝgÉ0iÉÄà ?
8.5.2 £ÉÆÃAzÀt «¨sÁUÀzÀ°è ¸Á®Ä
¤AwgÀĪÁUÀ EvÀgÉÃ
gÉÆÃVUÀ¼ÀÄ CªÁZÀå ±À§ÝUÀ¼À£ÀÄß
§¼À¹ »Ã£Á0iÀĪÁV
ªÀiÁvÀ£ÁrzÀgÀÄ ?
8.5.3 £ÉÆÃAzÀt «¨sÁUÀzÀ ¹§âA¢
£À£Àß ªÀÄvÀÄÛ EvÀgÉà gÉÆÃVUÀ¼À
ªÀÄzsÀåzÀ°è vÁgÀvÀªÀÄå J¸ÀVzÀgÀÄ
ªÀÄvÀÄÛ ¨ÉÃzsÀ¨sÁªÀ ªÀiÁrzÀgÀÄ.
8.5.4 £Á£ÀÄ QüÀÄ eÁw0iÀĪÀ£ÉAzÀÄ/
eÁw0iÀĪÀ¼ÉAzÀÄ £À£ÀߣÀÄß EvÀgÉÃ
gÉÆÃVUÀ¼ÀÄ §¢UÉ MwÛ
£ÉÆÃAzÀt ¸Á°£À°è £ÉÆÃAzÀtÂ
ªÀiÁr¸À®Ä ªÀÄÄAzÁzÀgÀÄ
8.6 ªÉÊzÀåjUÉ ¨sÉnÖ0iÀiÁUÀ®Ä ¸Á°£À°è PÁ0iÀÄÄwÛgÀĪÁUÀ
¤ÃªÀÅ ªÉÊzÀågÀ£ÀÄß PÁt®Ä ¸Á¯ÁV PÁ0iÀÄÄwÛgÀĪÁUÀ F 0iÀiÁªÀÅzÁzÀgÀÄ WÀl£É ¤ªÉÆäA¢UÉ
¸ÀA¨sÀ«¹zÉ0iÉÄÃ?
8.6.1 £Á£ÀÄ ¸ÀgÀ¢ §AzÁUÀ,
§®ªÀAvÀªÁV £À£Àß §zÀ®Ä
E£ÉÆßç⠪ÀåQÛ0iÀÄ£ÀÄß ªÉÊzÀågÀ£ÀÄß
PÁt®Ä ©qÀĪÀÅzÀÄ
8.6.2 ªÉÊzÀågÀ PÉÆoÀr0iÀÄ PÁªÀ®ÄUÁgÀ
CxÀªÁ D0iÀiÁ ªÉÊzÀågÀ
PÉÆoÀr0iÀÄ ºÉÆgÀUÉ gÉÆÃVUÀ¼À
¸Á®Ä PÁ¬ÄÝj¸ÀĪÁUÀ
£À£ÉÆßA¢UÉ QüÁV/CªÁZÀå
±À§ÝUÀ¼ÉÆA¢UÉ ªÀiÁvÀ£ÁrzÀÝ.
8.6.3 £Á£ÀÄ ªÉÊzÀågÀ£ÀÄß PÁt®Ä
¸Á°£À°è PÁ0iÀÄÄwÛgÀĪÁUÀ
EvÀgÉà gÉÆÃVUÀ¼ÀÄ £À£Àß ¥ÀPÀÌzÀ°è
PÀĽvÀÄPÉƼÀî®Ä
»Adj0iÀÄÄwÛzÀÝgÀÄ?
8.7 ªÉÊzÀågÉÆA¢UÉ ¸ÀªÀiÁ¯ÉÆÃZÀ£É ªÀiÁqÀĪÀ PÉÆoÀr: ¤ÃªÀÅ ªÉÊzÀågÉÆA¢UÉ ¸ÀªÀiÁ¯ÉÆÃZÀ£É
£ÀqɹgÀĪÁUÀ F 0iÀiÁªÀÅzÁzÀgÀÆ WÀl£ÉUÀ¼ÀÄ ¸ÀA¨sÀ«¹ªÉ0iÉÄà ?
8.7.1 ¸ÀªÀiÁ¯ÉÆÃZÀ£É0iÀÄ ¸ÀªÀÄ0iÀÄzÀ°è
ªÉÊzÀågÀÄ £À£ÉÆßA¢UÉ QüÁV
ªÀiÁvÀ£ÁrzÀgÀÄ.
8.7.2 ªÉÊzÀågÀÄ £À£ÀߣÀÄß ªÀÄÄlÄÖªÁUÀ
©gÀĸÁV ªÀwð¹zÀgÀÄ.
8.7.3 ªÉÊzÀågÀÄ £À£ÀߣÀÄß
¥ÀjÃQë¸ÀÄwÛgÀĪÁUÀ £À£ÀߣÀÄß
ªÀÄÄlÖ®Ä »Adj0iÀÄÄwÛzÀÝgÀÄ
8.7.4 ªÉÊzÀågÀÄ £À£ÉÆßA¢UÉ
EvÀgÀjVAvÀ PÀrªÉÄ ¸ÀªÀÄ0iÀÄ
PÀ¼ÉzÀgÀÄ
8.7.5 £À£Àß DgÉÆÃUÀåzÀ §UÉÎ
EvÀgÀjVAvÀ®Æ PÀrªÉÄ
ªÀiÁ»w0iÀÄ£ÀÄß £À£ÉÆßA¢UÉ
ºÀAaPÉÆAqÀgÀÄ
8.8 OµÀ¢üUÀ¼À «vÀgÀuÁ «¨sÁUÀ: ¤ÃªÀÅ ¤ªÀÄä OµÀ¢UÀ¼À£ÀÄß ¥ÀqÉ0iÀÄÄwÛgÀĪÁUÀ F 0iÀiÁªÀÅzÁzÀgÀÆ
WÀl£ÉUÀ¼ÀÄ ¸ÀA¨sÀ«¹ªÉ0iÉÄà ?
8.8.1. OµÀ¢ «vÀgÀuÉ ªÀiÁqÀĪÀAvÀºÀ
ªÀåQÛ £À£ÉÆßA¢UÉ QüÁV
DªÁZÀå ±À§ÝUÀ¼À£ÀÄß
ªÀiÁvÀ£ÁrzÀ£ÀÄ ?
8.8.2 OµÀ¢ ¤ÃqÀĪÀ ªÀåQÛ EvÀgÀjUÉ
PÉÊ0iÀÄ°è0iÉÄà OµÀ¢UÀ¼À£ÀÄß
¤ÃqÀÄwÛzÀÝgÀÆ £À£ÀߣÀÄß PÀAqÀ
vÀPÀët OµÀ¢UÀ¼À£ÀÄß PËAlgÀ
ªÉÄÃ¯É J¸ÉzÀÄ vÉUÉzÀÄPÉƼÀî®Ä
ºÉýzÀ.
8.8.3 £Á£ÀÄ £À£Àß OµÀ¢UÀ¼À£ÀÄß
vÉUÉzÀÄPÉƼÀî®Ä EvÀgÀjVAvÀ
ºÉaÑ£À ¸ÀªÀÄ0iÀĪÀ£ÀÄß
ªÀå¬Ä¸À¨ÉÃPÁ¬ÄvÀÄ
gÀPÀÛ vÀ¥Á¸ÀuÁ PÉÃAzÀæ ºÁUÀÆ JPÀìgÉ «¨sÁUÀ ¤ÃªÀÅ JPÀìgÉ «¨sÁUÀ CxÀªÁ gÀPÀÛ vÀ¥Á¸ÀuÁ
PÉÃAzÀæ/¯Áå§gÉÆÃlj ¸ÀAzÀ²ð¹zÁUÀ ¤ªÀÄä ¸ÀAUÀqÀ F 0iÀiÁªÀÅzÁzÀgÀÆ WÀl£É ¸ÀA¨sÀ«¹ªÉ0iÉÄÃ
?
8.9.1 C°è PÉ®¸À ªÀiÁqÀÄwÛgÀĪÀ
¹§âA¢0iÀĪÀgÀÄ £À£Àß ¸ÀAUÀqÀ
QüÁV
£ÀqÉzÀÄPÉÆAqÀgÀÄ/CªÁZÀå
±À§ÝUÀ¼À£ÀÄß §¼À¹
ªÀiÁvÀ£ÁrzÀgÀÄ.
8.9.2 £Á£ÀÄ £À£Àß ¥ÀjÃPÉëUÀ¼À£ÀÄß
¥ÀqÉ0iÀÄ®Ä EvÀgÀjVAvÀ®Æ
ºÉaÑ£À ¸ÀªÀÄ0iÀÄ
PÁ0iÀĨÉÃPÁ¬ÄvÀÄ.
8.10 aQvÁì PÉÆoÀr CxÀªÁ qÉæ¹ìAUÀ gÀÆA:
¤ÃªÀÅ aQvÁì PÉÆoÀr CxÀªÁ qÉæ¹ìAUï gÀƪÀÄ£À°ègÀĪÁUÀ F 0iÀiÁªÀÅzÁzÀgÀÆ WÀl£É ¤ªÀÄä
¸ÀAUÀqÀ ¸ÀA©ü«¹ªÉ0iÉÄà ?
8.10.1 PÁ0iÀÄð¤gÀvÀ ±ÀĵÀÆæµÀPÀgÀÄ /
¸ÀºÁ0iÀÄPÀgÀÄ £À£ÉÆßA¢UÉ
QüÁV
£ÀqÉzÀÄPÉÆAqÀgÀÄ/CªÁZÀå
±À§ÝUÀ¼À°è ªÀiÁvÀ£ÁrzÀgÀÄ.
8.10.2 PÁ0iÀÄð¤gÀvÀ ±ÀĵÀÆæµÀPÀgÀÄ /
¸ÀºÁ0iÀÄPÀgÀÄ £À£ÀߣÀÄß ªÀÄÄlÖ®Ä
»Adj0iÀÄÄwÛzÀÝgÀÄ
8.10.3 PÁ0iÀÄð¤gÀvÀ ±ÀĵÀÆæµÀPÀgÀÄ /
¸ÀºÁ0iÀÄPÀgÀÄ £À£Àß ¸ÀAUÀqÀ
©gÀĸÁV ªÀwð¹zÀgÀÄ
8.10.4 £À£Àß aQvÉì0iÀÄ£ÀÄß ¥ÀqÉ0iÀÄ®Ä £Á£ÀÄ
EvÀgÀjVAvÀ ºÉZÀÄÑ ¸ÀªÀÄ0iÀÄ
PÁ0iÀĨÉÃPÁ¬ÄvÀÄ ?
8.10.5 ±ÀĵÀÆæµÀPÀ «¨sÁUÀzÀ
¹§âA¢0iÀĪÀgÀÄ £À£Àß §UÉÎ CxÀªÁ
£Á£ÀÄ §¼À®ÄwÛgÀĪÀ PÁ¬Ä¯É0iÀÄ
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8.11 EvÀgÉà (CªÀ±ÀåªÉ¤¹zÀÝ°è) EªÀÅUÀ¼À°è 0iÀiÁªÀÅzÁzÀgÀÆ WÀl£ÉUÀ¼ÀÄ ¤ªÉÆäA¢UÉ ¸ÀA¨sÀ«¹ªÉ0iÉÄà ?
8.11.1 ____________ À̧ºÁ0iÀÄPÀ
¤ªÀÄä ¸ÀAUÀqÀ QüÁV
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8.11.2 __________ ¹§âA¢0iÀĪÀgÀÄ,
£À£ÀߣÀÄß ¥ÀjÃQë¸ÀÄwÛgÀĪÁUÀ
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8.11.3 __________ À̧àµÀð
C¸ÀA»vÀªÁVvÀÄÛ.
8.11.4 ________EvÀgÀjVAvÀ ºÉZÀÄÑ
ºÉÆvÀÄÛ £À£Àß ¸ÉêÉ0iÀÄ£ÀÄß ¥ÀqÉ0iÀÄ®Ä
PÁ0iÀÄĪÀAvÉ ªÀiÁrzÀgÀÄ.
8.11.5 __________£À£Àß PÁ¬Ä¯É0iÀÄ
§UÉÎ £ÀUÉ0iÀiÁqÀÄwÛzÀÝgÀÄ ªÀÄvÀÄÛ £À£Àß
§UÉÎ QüÁV ªÀiÁvÀ£ÁrzÀÝgÀÄ
9. £ÀªÀÄä Hj£À
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CxÀªÁ
aQvÀìPÀgÀÄ.
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CwøÁgÀ ¨ÉÉâü0iÀiÁzÁUÀ
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2. SÁ¸ÀV D¸ÀàvÉæ
3. SÁ¸ÀV zÀªÁSÁ£É
4. OµÀzÁ®0iÀÄ
5. ¥ÁgÀA¥ÀjPÀ aQvÀìPÀgÀÄ
6. ªÉÊzÀågÀÄ/ºÀQêÀÄ/ºÉÆëÄ0iÀÄ¥ÀyPÀ
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7. EvÀgÉÃ
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1. ¸ÀgÀPÁj D¸ÀàvÉæ
2. SÁ¸ÀV D¸ÀàvÉæ
3. SÁ¸ÀV zÀªÁSÁ£É
4. OµÀzÁ®0iÀÄ
5. ¥ÁgÀA¥ÀjPÀ aQvÀìPÀgÀÄ
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EvÀgÉÃ
10 PÀ¼ÉzÀ JgÀqÀÄ
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CwøÁgÀ
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PÁ¬Ä¯ÉUÀ½AzÀ
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ªÀÄUÀÄ«UÉ CwøÁgÀ
¨Éâü0iÀiÁVvÉÛà ?
1. ºËzÀÄ
2. E®è
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ªÀÄUÀÄ«UÉ J.Cgï.L.
DVvÉÛÃ?
1. ºËzÀÄ
2. E®è
¥Àæ±Éß 10 gÀ°è J CxÀªÁ © 0iÀÄ°è ºËzÀÄ JAzÀÄ GvÀÛj¹zÀÝgÉ CxÀªÁ J ªÀÄvÀÄÛ © JgÀqÀgÀ®Æè ºËzÀÄ JAzÀÄ
GvÀÛj¹zÀÝgÉ ¥Àæ±Éß 11 PÉÌ ºÉÆÃVj CxÀªÁ CªÀgÀ£ÀÄß vÀªÀÄä CªÀÄÆ®åªÁzÀ ¸ÀªÀÄ0iÀĪÀ£ÀÄß ¤ÃrzÀÝPÁÌV ªÀA¢¹
¸ÀAzÀ±ÀðªÀ£ÀÄß E°èUÉ ªÀÄÄPÁÛ0iÀÄUÉƽ¹. If “Yes” for both Diarrhea/ARI or Diarrhea or ARI then proceed
to 12, if “No” for both then thank them for their time and end the interview.
11 Cw¸ÁgÀ ¨Éâ0iÀiÁzÀ°è ªÀÄUÀÄ«£À
¨Éâ0iÀÄ°è gÀPÀÛzÀ CA±À PÀAqÀÄ
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1. ºËzÀÄ
2. E®è
“J.Dgï.L.”¢AzÀ ªÀÄUÀÄ
§¼À°zÀÝgÉà CzÀPÉÌ F
0iÀiÁªÀÅzÁzÀgÀÆ ®PÀëtUÀ¼ÀÄ
PÀAqÀÄ §A¢gÀÄvÀÛªÉ0iÉÄà ?
1. PɪÀÄÄä
1 ºËzÀÄ 2 E®è
2. G¹gÁqÀ®Ä vÉÆAzÀgÉ
3. Cwà ªÉÃUÀzÀ G¹gÁl
4. JzÉ0iÀÄ ¨sÁUÀzÀ°è
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5. dégÀ
6. ¥ÀæeÉÕ vÀ¥ÀÅöàªÀÅzÀÄ.
1 ºËzÀÄ 2 E®è
1 ºËzÀÄ 2 E®è
1 ºËzÀÄ 2 E®è
1 ºËzÀÄ 2 E®è
1 ºËzÀÄ 2 E®è
12 ªÀÄUÀĪÀÅ CwøÁgÀ ¨Éâü¬ÄAzÀ
CxÀªÁ G¹gÁlzÀ
vÉÆAzÀgɬÄAzÀ JµÀÄÖ PÁ®
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PÀgÉzÀÄPÉÆAqÀÄ ºÉÆÃV¢ÝÃgÁ ?
1. ºËzÀÄ
2. E®è
¥Àæ±Éß 13 PÉÌ ºËzÀÄ JAzÀÄ GvÀÛj¹zÀÝgÉ £ÉÃgÀªÁV ¥Àæ±Éß 15 PÉÌ ºÉÆÃV E®èªÁzÀ°è ªÀÄÄAzÀĪÀgɹ. If “Yes” go
to Q15, if “No” then proceed to next question
14 ªÀÄ£É0iÀÄ ºÉÆgÀUÉ aQvÉì
¥ÀqÉ0iÀÄ®Ä
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aQvÉì0iÀÄ£ÀÄß ªÀģɬÄAzÀ
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ºÉZÀÄÑ PÁgÀtUÀ¼À£ÀÄß
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1) zÀªÁSÁ£É / ªÉÊzÀåQÃ0iÀÄ
PÉÃAzÀæ ªÀģɬÄAzÀ CwÃ
zÀÆgÁVgÀÄvÀÛªÉ?
2) ªÀÄUÀĪÀ£ÀÄß aQvÉìUÁV
PÀgÉzÉÆ0iÀÄå®Ä 0iÀiÁªÀzÉÃ
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3) ¸ÁjUÉ0iÀÄ ªÉZÀÑ CwÃ
ºÉZÁÑVgÀÄvÀÛzÉ.
4) aQvÉì0iÀÄ ªÉZÀÑ Cw
ºÉZÁÑVgÀÄvÀÛzÉ.
5) ªÀÄ£É0iÀÄ°è EvÀgÉà ªÀÄPÀ̼À
DgÉÊPÉUÁV 0iÀiÁgÀÆ
EgÀĪÀÅ¢®è
6) ¢£ÀPÀÆ° PÀ¼ÉzÀÄPÉƼÀÄîªÀ
¨sÀ0iÀÄ.
7) ªÀÄ£É0iÀÄ°è ¥ÀjuÁªÀÄPÁj
aQvÉì ¤ÃqÀ¯Á¬ÄvÀÄ.
8) EvÀgÉÃ
F ¥Àæ±Éß ¸ÀASÉå 15 £ÀÄß GvÀÛj¹zÀgÉ £ÉÃgÀªÁV ¥Àæ±Éß ¸ÀASÉå 19 PÉÌ ºÉÆÃV . After answering this question
go to question 19
15 aQvÉì ¥ÀqÉ0iÀÄ®Ä
vÀqÀªÁVzÀÝgÉ
¨Éâü ªÀ G¹gÁlzÀ vÉÆAzÀgÉ0iÀÄ
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¢£ÀUÀ¼À £ÀAvÀgÀ D¸ÉàvÉæ ªÀÄvÀÄÛ
ªÉÊzÀågÀ£ÀÄß PÀArgÀÄ«j ?
15.1 PɪÀÄÄä / ¨ÉâüUÀ¼À ®PÀët PÀAqÀÄ §AzÀ
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15.2 ®PÀëtUÀ¼ÀÄ PÀAqÀÄ §AzÀ CAzÁdÄ
¸ÀªÀÄ0iÀÄ
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PÀgÉzÉÆ0iÀÄÝ ¢£ÁAPÀ
15.4 D¸ÀàvÉæ CxÀªÁ ªÉÊzÀågÀ£ÀÄß vÀ®Ä¥À®Ä
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16. ªÀÄ£É0iÀÄ°è0iÉÄÃ
¤ÃrzÀ aQvÉì
D¸ÀàvÉæ CxÀªÁ ªÉÊzÀågÀ£ÀÄß PÁtĪÀ
ªÀÄÄ£Àß ªÀÄ£É0iÀÄ°è0iÉÄà 0iÀiÁªÀÅzÁzÀgÀÆ
aQvÉì0iÀÄ£ÀÄß ªÀiÁr¢ÝÃgÁ ?
1. ºËzÀÄ
2. E®è
16.1 ºËzÁzÀ°è ¤ÃªÀÅ ¤ÃrzÀ
aQvÉì0iÀÄ/aQvÉìUÀ¼À «ªÀgÀ, gÉÆÃUÀ
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PÀæªÀħzÀÞªÁV «ªÀj¹ ?
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2 £ÉÃ
3 £ÉÃ
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1.1 ¸ÀgÀPÁj/£ÀUÀgÀ ¥Á°PÉ D¸ÀàvÉæ
1.2 ¸ÀgÀPÁj zÀªÁSÁ£É
1.3 ¥ÁæxÀ«ÄPÀ DgÉÆÃUÀå PÉÃAzÀæ
1.4 ¸ÀªÀÄÆzÁ0iÀÄ DgÉÆÃUÀå
PÉÃAzÀæ/UÁæ«ÄÃt D¸ÀàvÉæ
1.5 G¥À PÉÃAzÀæ /Qj0iÀÄ DgÉÆÃUÀå
¸ÀºÁ0iÀÄPÀgÀÄ
1.6 ¸ÀgÀPÁj ¸ÀAZÁj zÀªÁSÁ£É
1.7 CAUÀ£ÀªÁr PÉÃAzÀæ/ L.¹.r.J¸ï.
PÉÃAzÀæ
1.8 D±Á PÁ0iÀÄðPÀvÀðgÀÄ
1.9 EvÀgÉÃ
2. SÁ¸ÀV ªÉÊzÀåQÃ0iÀÄ gÀAUÀ
2.1 SÁ¸ÀV D¸ÀàvÉæ
2.2 SÁ¸ÀV ªÉÊzÀågÀÄ/zÀªÁSÁ£É
2.3 SÁ¸ÀV CgÉ ªÉÊzÀåQÃ0iÀÄ ¹§âA¢
2.4 ªÉÊzÀå/ºÀQêÀiï/ºÉÆëÄ0iÉÆÃ¥ÀyPÀ
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2.5 ¥ÁgÀA¥ÀjPÀ ªÉÊzÀågÀÄ
2.6 OµÀzÁ®0iÀÄ/OµÀ¢ CAUÀr
2.7 EvÀgÉÃ______
3. J£ï.f.N./læ¸ïÖ/Qè¤Pï
4. EvÀgÉÃ
4.1 CAUÀrUÀ¼À°è
4.2 UɼÉ0iÀÄjAzÀ/¸ÀA§A¢üUÀ½AzÀ
4.3 EvÀgÉÃ _________
18 ¨Éâü0iÀÄ aQvÉìUÁV
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¤Ãr¢ÝÃgÁ ?
1. ºËzÀÄ 2. E®è 3. ªÀiÁ»w EgÀĪÀÅ¢®è.
J.Dgï.L. aQvÉìUÁV
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1. ºËzÀÄ 2. E®è 3. ªÀiÁ»w EgÀĪÀÅ¢®è.
ºËzÁzÀ°è ¥Àæ±Éß 18.1 ªÀÄvÀÄÛ 18.2 UÉ ºÉÆÃV E®èªÉAzÀ°è ¥Àæ±Éß 19 PÉÌ ªÀÄÄAzÀĪÀgɬÄj. If “yes” then go to 18.1 or
18.2, if “no” or “Don’t know” skip to 19 18.1 Cw¸ÁgÀ ¨Éâü0iÀÄ£ÀÄß
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1. DAn§0iÀiÁnPï
2. DAmÉƪÉÆn°n
3. fAPï
4. EvÀgÉà ( ªÉÄïÁÌt¹zÀªÀÅUÀ¼À£ÀÄß
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5. OµÀ¢0iÀÄ ¸ÀégÀÆ¥À w½¢gÀĪÀÅ¢®è
ZÀÄZÀÄѪÀÄzÀÄÝ:
6. DAn§0iÀiÁnPï
7. £Á£ï DAn§0iÀiÁnPï
8. ZÀÄZÀÄѪÀĢݣÀ ºÉ¸ÀgÀÄ w½¢gÀĪÀÅ¢®è
9. EAmÁæªÉãÀì
10. ªÀÄ£É0iÀÄ
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vÀ0iÀiÁgÁzÀ OµÀ¢üUÀ¼ÀÄ
11. EvÀgÉÃ _____
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1. DAn§0iÀiÁnPï
2. EvÀgÉÃ
3. OµÀ¢0iÀÄ ¸ÀégÀÆ¥À
w½¢gÀĪÀÅ¢®è
ZÀÄZÀÄѪÀÄzÀÄÝ:
4. DAn§0iÀiÁnPï
5. £Á£ï DAn§0iÀiÁnPï
6. ZÀÄZÀÄѪÀĢݣÀ ºÉ¸ÀgÀÄ
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7. EAmÁæªÉãÀì
8. ªÀÄ£É0iÀÄ ªÀÄzÀÄÝUÀ¼ÀÄ/
VqÀªÀÄÆ°PÉUÀ½AzÀ vÀ0iÀiÁgÁzÀ
OµÀ¢üUÀ¼ÀÄ
9. EvÀgÉÃ _____
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PÉÃAzÀæ/zÀªÁSÁ£É/D¸ÀàvÉæUÉ
PÀgÉzÉÆ0iÀÄÝ PÁgÀtUÀ¼ÉãÀÄ
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Qualitative Component
In-depth Interview guidelines
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DgÉÆÃUÀå ¸Ë®¨sÀåUÀ¼À §UÉÎ ¤ªÀÄä C¤¹PÉ ºÉÃVgÀÄvÀÛzÉAzÀÄ Cj0iÀÄ®Ä GvÀÄìPÀ£ÁVzÉÝãÉ.
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JzÀÄj¸ÀÄwÛâÝÃgÁ ?
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